>>WELCOME TO THE 17ANNUAL PAIN CONSORTIUM. USE YOUR Q&A BOX. THERE'S NO MICROPHONE OR CAMERA OPTIONS FOR OUR ATTEND'S, FOR OUR SPEAKERS AND PANELISTS REMAIN ON MUTE UNTIL YOUR PANEL SESSION IN Q&A AND KEEP YOUR CAMERAS OFF UNTIL YOUR Q&A AND DISCUSSION PANEL SESSIONS SUBMIT QUESTIONS FOR OTHER SPEAKERS AND ANY TIME DURING THEIR PRESENTATIONS THROUGH THE CHAT FUNCTION. FOR TECHNICAL ASSISTANCE, IF YOU NEED ZOOM, TECHNICAL ASSISTANCE, DIRECTING MESSAGE HALIGONIANS HY HARRINGTON OR SUBMIT A QUESTION OR E-MAIL HOLLY AT THE WEBSITE. PLEASE NOTE THIS WORKSHOP IS STREAMING LIVE ON NIH WEBCAST WITH LIVE CLOSED CAPTIONING AND IT'S BEING RECORDED AND WILL BE VIEWED AND ARCHIVED FOR LATER VIEWING. AND WE'D LIKE TO INTRODUCE Dr. LEAH. >> GOOD MORNING, EVERYONE. I'M FROM THE OFFICE OF PAIN POLICY AND PLANNING AT THE NATIONAL INSTITUTE FOR NEUROLOGICAL DISORDER AND STROKE. WE HOPE TO BE ABLE TO WELCOME YOU ALL BACK IN THE FUTURE BUT FOR NOW WE'RE STILL VIRTUAL SO I'M GOING TO INTRODUCE YOU FOR THE NEXT FEW DAYS. THE CHAIRS OF THE PC SYMPOSIUM PLANNING COMMITTEE THIS YEAR. Dr. EINABELL FER FOR -- WHERE SE MANAGED PART OF THE PAIN NCCI PAIN FORT FOAL. MELISSA GHIM SAY PROGRAM DIRECTOR AT THE NATIONAL INSTITUTE OF DIDN'TAL AND CRANE YAN AND FACIAL RESEARCH WHERE SHE MANAGES THE NEUROSCIENCE OF (INAUDIBLE) AND THE DISORDER FORT FOAL. THEY HAVE WORKED TIRELESSLY TO PUT THIS PROGRAM TOGETHER FOR YOU AND LEAD US THROUGH THE NEXT FEW DAYS. YOU WILL SEE THEM POPPING UP TO SHEPHERD US ALONG. WITH THAT IT'S MY PLEASURE TO INTRODUCE Dr. WALTER KOROSHETZ, THE DISTRICT OR OF NEUROLOGICAL STROKE AND CHAIR OF THE NIH PAIN CONSORTIUM EXECUTIVE COMMITTEE TO OFFICIALLY WELCOME YOU TO THE SYMPOSIUM THIS YEAR. THANK YOU. >> THANK YOU, VERY MUCH. AND ARE YOU SEEING THE SLIDES CORRECTLY? >> THANK YOU. SO AS I MENTIONED I'M WALTER KOROSHETZ AND THIS IS OUR 17th ANNUAL AND NIH PAIN CONSORTIUM SYMPOSIUM AND I WANT TO WELCOME EVERYONE AND EMPHASIS HOW IMPORTANT THIS SYMPOSIUM IS FOR PAIN RESEARCH GOING FORWARD AND TODAY, THE FOCUS OF THE SYMPOSIUM IS PAIN MANAGEMENT THROUGH THE LENS OF A WHOLE PERSON HEALTH. CLEARLY, I'M SURE MANY OF YOU ON THE SYMPOSIUM TODAY UNDERSTAND HOW PAIN EFFECTS SO MANY DIFFERENT OTHER SYSTEMS IN OUR BODIES WHETHER IT'S MOOD, MOBILITY, IT ALL CONTRIBUTES TO DECREASING THE PERSON'S ABILITY TO FUNCTION THE WAY THEY WOULD LIKE TO IN THE WORLD AND THEN ALSO, HOW THERE ARE SO MANY OTHER THINGS THAT HAPPEN TO US, CO-MORBIDITIES, WHETHER THERE ARE HEALTH RELATED INJURY RELATED THAT IMPACT ON PAIN. SO BEING ABLE TO STEER THE PROBLEM FROM THE PERSON WHO IS EXPERIENCING IT, THROUGH THAT LENS, IS WHAT WE'RE GOING TO BE TALKING ABOUT TODAY AND I JUST WANTED TO MENTION, WE CAN'T HELP BUT MENTION THAT THE REASON WHY THESE SYMPOSIUM NOW ARE MORE PORT AN THAN EVER IS BECAUSE WITH THE HEEL INITIATIVE HELPING TO END ADDICTION LONG-TERM, NIH HAS RECEIVED CONSIDERABLE FUNDS TO KIND OF DO THINGS AT THE RESEARCH LEVEL THAT WERE PREVIOUSLY UNMANAGE ABLE SO WE HAVE A TREE MEN -- UNIMAGINABLE. SO WE CAN HOPEFULLY GET BETTER TREATMENTS FOR PATIENTS AND THESE ARE REALLY IMPORTANT IN KIND OF ADVISING OR INFORMING THE NIH FOLKS ON WHICH WAY TO MOVE THOSE PROGRAMS. SO, AGAIN, REALLY IMPORTANT TOPIC AND GO TO THE NEXT SLIDE. I HAVE THIS CONTROL. SO, JUST TO MENTION THE PAIN CONSORTIUM HAS BEEN AROUND AS I SAID, FOR OVER 17 YEARS AND IT'S MULTIPLE DIFFERENT INSTITUTES AT NIH AND WE'RE ALL GALVANIZED BY OUR MISSION TO ENHANCE PAIN RESEARCH, PROMOTE COLLABORATIONS ACROSS THE INSTITUTES AND TO HAVE PROGRAMS AND ACTIVITIES THAT ADDRESS PAIN AND AS I MENTIONED WITH THE HEAL INITIATIVE, WE ARE FUNDING THAT WE NEVER HAD BEFORE TO DO THAT KIND OF THING. THE LEADERSHIP FOR THE PAIN CONSORTIUM IS REALLY DISTRIBUTED BETWEEN MYSELF THAT Dr. LANGEVIN AND SHANNON ZENK, Dr. D'SOUZA AND Dr. VOLKOW AND THIS IS THE PEOPLE THAT PUT TOGETHER FROM THE PAIN POLICY AND PLANNING AND LEAH AND LAURA WANDNER AND LINDA PORTER WHO RUNS THAT OFFICE. THANK YOU FOR THE PEOPLE DOING THE WORK YEAR IN AND YEAR OUT. THESE ARE THE LIST OF THE INSTITUTES AND CENTER INVOLVED IN THE PAIN CONSORTIUM AT NIH SO IT'S PRETTY MUCH ANY DISEASE ORGANIZATION AND NUMBER OF DIFFERENT OFFICES ALL HAVE PAIN AS PART OF THEIR MISSIONS AND OUR JOB IN THE PAIN CONSORTIUM IS TO KIND OF COLLABORATE ACROSS ALL THESE INSTITUTES AND CLEARLY THE EMPHASIS TODAY WILL BE HEAVILY ON SOME OF THE INSTITUTES PARTICULARLY NCCIH, NURSING INSTITUTES, BUT ALL OF THE INSTITUTES HERE LISTED WILL HAVE INTEREST. AND SO THE PANEL SESSIONS WE'LL BE TALKING ABOUT IS THE COMMENT PLEX TEE OF PLAIN AND CO-MORBIDITY AND INTEGRATION WHOLE PERSON TOOLS AND APPROACHES AND WHOLE PERSON APPROACHES TO PAIN MANAGEMENT. AND WITH THAT I AM REALLY HAPPY TO INTRODUCE OUR KEYNOTE SPEAKER, TRACY GAUDET. SHE IS THE EXECUTIVE DIRECTOR OF THE WHOLE HEALTH INSTITUTE AND IT'S A PHILANTHROPIC INSTITUTE DEDICATED TO REALLY TRANSFORM HOW HEALTH IS SEEN, DELIVERED, ASSESSED, WITH THE WHOLE PATIENT IN MIND AND SO COULDN'T HAVE A BETTER SPEAK ARE FOR TODAY'S SYMPOSIUM AND PRIOR TO GOING TO WHOLE HEALTH, SHE WAS THE EXECUTIVE DIRECTOR AT THE V.A. ADMINISTRATION'S NATIONAL OFFICE OF PATIENT CENTERED CARE AND CULTURAL TRANSFORMATION AND SO THROUGH A LOT OF EXPERIENCE AND THAT HEALTH-CARE SYSTEM WHICH IS THE ONE WE WORK WITH HEAVILY HERE AT NIH TO ACTUALLY TEST NEW WAYS OF MANAGING PAIN IN HEALTHCARE SYSTEMS. AND PREVIOUS TO THAT, OUR EXTENT WITH THE V.A. SHE WAS WITH THE DUKE UNIVERSITY HEALTH SYSTEM AND SHE RECEIVED THE NATION'S VETERANS WITH EX POLICE CAR' SERVICE AWARD AND THE VISIONARY AWARD OF THE ACADEMY OF INTEGRATED HEALTH AND MEDICINE FOR HER LEADERSHIP IN TRANSFORMING HEALTHCARE AND TRACY, WE'RE INTERESTED TO HEAR YOUR THOUGHTS AND ON RESEARCH AND PATIENTS SUFFERING WITH PAIN AND NOT REALLY GETTING THE RELIEF TO GET TO THE FUNCTIONAL LEVEL THEY'D LIKE TO GET TO. WITH THAT I WANT TO HAND IT OVER TO TRACY. THANK YOU, VERY MUCH. I'LL STOP SHARING. >> THANK YOU SO VERY MUCH AND I WILL SAY A LITTLE BIT AT CLOSE OF MY TIME WITH YOU THIS MORNING. HOW SIGNIFICANT I THINK THIS MEETING IS AND HOW HONORED I AM TO BE A PART OF LAUNCHING THE CONVERSATIONS. SO, THANK YOU VERY MUCH. THERE'S NEVER BEEN A MORE IMPORTANT TIME FOR THIS CONVERSATION. SO, I'M GOING TO MOVE RIGHT INTO MY SLIDES. I LOVE THE FACT THAT WE'RE ASKING QUESTIONS OF HOW CAN A WHOLE HEALTH APPROACH INFORM HOW WE THINK ABOUT TREAT, RESEARCH, THE ISSUES OF PEOPLE DEALING WITH PAIN AND SO I THINK YOU GUYS ARE OPERATING MY SLIDES IF I AM UNDERSTANDING THAT RIGHT. HE CAN GO AHEAD AND SAY THAT I THINK YOU KNOW, I'M GOING TO START WITH A FEW ILLUSTRATIONS OF CONTEXT SINCE THIS IS THE KICKOFF TO THE CONVERSATION OVER THE NEXT TWO DAYS ABOUT -- ARE YOU SEEING MY SLIDES BECAUSE I AM NOT? >> NOT YET. >> GREAT. NOW YOU CAN GO TO THE NEXT SLIDE. I WANTED TO MAKE SURE THAT I AM ON THE SAME PAGE AS THE REST OF YOU ALL. IN TERMS OF SETTING THE LARGER CONTEXT, I KNOW MOST PEOPLE IN THIS AUDIENCE ARE VERY FAMILIAR WITH THIS BUT I THINK IT'S IMPORTANT THAT WE STOP AND PAUSE AND LOOK AT LARGER CONTEXT OF WHAT WE'RE DEALING WITH HERE THAT IF WE THINK ABOUT HEALTHCARE IN GENERAL AND THE UNITED STATES, WE ARE IN A DIRE SITUATION AS PEOPLE KNOW, FINANCIALLY, IT'S INCREDIBLE AND WE'RE UP TO 20% OF OUR G.D.P. AND GOING TOWARDS HEALTHCARE COSTS AND WHILE OUR OUTCOMES ARE NOT WHAT WE WANT. IF YOU LOOK AT LIFE EXPECTANCY, ALL 2020 OUR LIFE EXPECTANCY DECREASED TO 77 YEARS AND WHEN YOU COMPARE US TO OTHER COUNTRIES, COMPARABLE COUNTRIES ARE ABOUT 81.1 YEARS IN 2020 SO THE GAP BETWEEN US AND THE OTHER PEER COUNTRIES IS WIDENING. CHRONIC CONDITIONS ARE CONSUMING A VAST MAJORITY OF THAT HAVE AND THE KEY FOR THIS CONVERSATION IS THAT MUCH OF CHRONIC CONDITION IS IMPACTED BY PEOPLE'S LIFESTYLE, BEHAVIOR, CHOICES, AND THE BOTTOM LINE IS IN CERTAINLY MY OPINION AND MANY OTHERS IS ONE OF THE MAJOR PROBLEMS THAT WE HAVE UNDERLINING THIS CRISIS, IS THAT THE CURRENT APPROACH TO HEALTH AND DISEASE MANAGEMENT, ACTUALLY DOESN'T FOCUS ON ENGAGING PEOPLE AND OPTIMIZING THEIR SELF-CARE AND WELL BEING SO WE DO PARTS OF HEALTHCARE VERY EFFECTIVELY AND THE ASPECTS THAT ARE SO CRITICAL TO THESE OUTCOMES AND THE COST WE DON'T REALLY PAY ATTENTION TO. THE SYSTEM ITSELF, NOT INDIVIDUALS, THIS IS NOT ABOUT THE INDIVIDUAL CLINICIANS OR RESEARCHERS BUT THE SYSTEM IS NOT DESIGNED AS A CORE COMPETENCY TO ENGAGE PEOPLE IN THEIR OWN SEVERAL CARE AND TEACH THEM THE SKILLS THEY NEED TO DO THAT EFFECTIVELY. WE'RE GOING TO TALK MORE ABOUT THIS. I THINK THE OPIOID CRISIS FROM MY PERSPECTIVE IS A VERY CLEAR DEMONSTRATION OF THE LIMITATIONS OF WHAT I WOULD CALL A FIND IT, FIX IT OR A REDUCTION IS TICK PARADIGM THAT I THINK WE NOW HAVE WITH THE LEADERSHIP OF THIS GROUP, HAVE AN OPPORTUNITY TO REALLY, REALLY TRANSFORM IN A VERY SIGNIFICANT WAY. THIS IS A LITTLE SHOCKING WHEN YOU LOOK AT THE LINE. THE PURPLE LINE IS THE PER-CAPITA SPENDING IN THE NATIONS ACROSS THE BOTTOM. TRACTOR-TRAILER THE AVERAGE LIFE EXPECTANCY AND YOU CAN SEE AND AND IT'S WAY DOWN THE LINE NEXT TO CUBA IN TERMS OF LIFE EXPECT ANTSY SO ANOTHER WAY TO PAINT THE PICTURE OF THE PROBLEM WE'RE FACING. AND I LOVE THIS. I WOULD ENCOURAGE YOU TO HOLD THIS QUOTE IN YOUR CON SUNNESS CONSCIOUSNESS. PROBLEMS CANNOT BE SOLVED WITH THE SAME LEVEL OF THINKING THAT CREATED THEM. AS I'M UNDERSTANDING THE INTENTIONS FOR THE TWO DAYS, IT'S TO LAUNCH US INTO ADVANCING OUR THINKING ABOUT THE PROBLEMS WE'RE FACING AND HOW WE THINK OF THIS DIFFERENTLY. IN A DIFFERENT WAY, DOING MORE OF THE SAME IS NOT GOING TO FIX THE PROBLEM THAT WE'RE CURRENTLY FACING. SO NEXT SLIDE, PLEASE. A QUICK GLANCE AT -- IF YOU CLICK AGAIN, I DIDN'T KNOW I PHASED THAT. THERE WE GO, THANK YOU. A QUICK LOOK AT OVERLY SIMPLIFIED VERSION BUT I THINK A USEFUL PERSPECTIVE WHEN WE'RE TALKING ABOUT CHANGING OUR PARADIGMS AND LOOKING AT THE COMMENT PLCOMPLEXITY OF PAIN, YK ABOUT OUR SCIENCE IN THE 1900S COMPARED TO THE 2000s, SCIENCE HAS ADVANCED TREMENDOUSLY, RIGHT. WE'VE GONE FROM UNDERSTANDING WHAT THE LIST AND WE'VE GONE FROM A REDUCTIONISTIC APPROACH AND THE 1900S AND RESULTED IN AN APPROACH OF FINDING A CORE PROBLEMS AND FIXING IT AND AND THOSE THINGS ARE GREAT WHEN YOU CAN DO THAT BUT WHAT WE LEARNED IT'S NOT THAT SIMPLE AND THESE THINGS ARE VERY COMPLEX AND OUR SCIENTIST ADVANCE INTO MUCH MORE OF A SYSTEMS APPROACH BUT I WOULD PROPOSE TO YOU THAT OUR MEDICAL APPROACHES HAVE NOT KEPT PACE WITH THAT. NEXT SLIDE. WHEN WE THINK ABOUT THIS WHEN WE TALK BASIS TOMORROW'S THAT THE APPROACH AND PARADIGMS WE REALLY FELT LIKE OK, IF WE CAN FIND THE PROBLEM, WE CAN CREATE THE SOLUTION AND FIX THE PROBLEM BUT THAT IS A VERY CONCEPT OF A SINGLE FACTOR AND THERE'S A MICROBE CAUSING AN INFECTION AND WE JUST CREATE THE CURE FOR THAT AND WE'RE GOOD TO GO. NEEDLESS TO SAY IT'S NOT THAT SIMPLE. CERTAINLY PAIN AND PEOPLE'S SUFFERING WITH PAIN, ARE ONE OF THE MOST IS POIGNANT ILLUSTRATIONS OF HOW COMPLEX THESE ILLUSTRATIONS ARE. THERE ARE FACTORS IN THE PERSON THEMSELVES AND ALSO IN THEIR ENVIRONMENT. THERE IS THEIR GENOMIC RISK AND SOCIAL DETERMINANTS, LIFESTYLE CHOICES, WE ARE COMPLEX ADAPTIVE SYSTEMS AND YET I THINK OUR MEDICAL APPROACH, AND I WOULD LEAVE IT TO YOU TO SAY, IF OUR RESEARCH APPROACH, HAS CAUGHT UP TO THAT AND ADVANCED BEYOND THE MORE REDUCTIONISTIC APPROACH. IT'S A BIG CHALLENGE THAT WE'RE FACING RIGHT NOW. >> I'M A PHYSICIAN CLINICIAN AND LOOKING AT HEALTHCARE DELIVERY SO I'M BEING CRITICAL OF THE WORLD I COME FROM AND THE SCIENCE HAS ADVANCED MUCH FURTHER THAN THE HEALTHCARE DELIVERY AND ONE ILLUSTRATION OF THIS, YOU KNOW, THE NOBEL PRIZE IN 2018 WAS AWARDED BASED ON THIS IS THE LANGUAGE THAT WAS DESCRIBED, THAT THIS IS A NEW PRINCIPLE FOR TREATMENT AND THIS WAS CANCER TREATMENT AND WHERE PREVIOUS TREATMENTS TARGETED THE CANCER CELLS AND THIS TARGETED THE HOST SO WHAT THAT MEANT IS IN THE SCIENCE DONE BY THESE TWO GENTLEMAN, INSTEAD OF FIGHTING THE CANCER CELL AND THE FIND IT AND FIX IT MODEL, WE'RE GOING TO FIND THE CANCER CELLS AND FIND NEW WAYS TO DESTROY THE CANCER CELLS, THEIR PRIZE WAS AWARDED BECAUSE THEY WERE ACTUALLY LOOKING AT THE HOST, MEANING THE PERSON, AND COULD THE TREATMENTS FOCUS ON, THIS IS MY LANGUAGE, NOT THEIRS BUT COULD THE TREATMENTS FOCUS ON THE AMPLIFYING THE BODIES OWN INNATE CAPACITY TO FIGHT THE CANCER CELLS. IT'S A SWITCH IN THAT PARADIGM THAT WAS RECOGNIZED AS VERY TRANSFORMATIONAL AND I WOULD PROPOSE TO YOU, IN MY EXPERIENCE, THAT THE HEALTHCARE DELIVERIES SYSTEM HAS NOT ADVANCED IN THE SAME WAY. AND THAT WE'RE STILL VERY MUCH CAUGHT IN THE FIND IT-FIX-IT REDUCTIONISTIC APPROACH IN LARGE PART BECAUSE THAT'S WHAT THIS SYSTEM IS SET UP TO DO AND THAT'S WHAT WE'RE PAID TO DO PRIMARILY SO IT'S NO ONE'S FAULT, IT'S A SYSTEMS ISSUE BUT THINK WE HAVE TO RECOGNIZE THE SYSTEMS ISSUE IF WE'RE GOING TO ADDRESS IT. NEXT SLIDE. I WANTED TO REFLECT A BIT ON HOW WE'VE BEEN TRAINED TO THINK. AGAIN, I'M A PHYSICIAN BY TRAINING AND SO I AM JUST REFLECTING AND I THINK WE HAVE GOTTEN BETTER THAN WHEN I WAS IN MEDICINE SCHOOL AND RESIDENTS DEN SEE BUT IT'S USEFUL WHEN WE'RE THINKING ABOUT CHANGING THE LENS, THROUGH WHICH WE LOOK, WHICH Dr. KOROSHETZ SHARED AND WHAT HAPPENS WHEN WE CHANGE THE LENS? I WANTED TO TAKE A MOMENT TO LOOK AT LENS THROUGH WHICH MOST OF US HAVE BEEN TRAINED TO THINK IF YOU THINK ABOUT WELL ASK YOURSELF HOW DO ANTIBIOTICS WORK? MOST OF US WILL SAY THE ANTIBIOTICS ANTI-BUYOT CURE THEE THEY KILL OFF THE MICROBES. A DIFFERENT WAY, PARALLEL TO THE NOBEL PRIZE-WINNING CANCER SHIFT AND A DIFFERENT WAY TO THINK ABOUT THAT IS YEAH, THEY ABSOLUTELY HELP BUT PERHAPS THE WAY WE CAN THINK ABOUT THAT IN A DIFFERENT LENS TO THINK ABOUT THAT IS THE ANTIBIOTICS REDUCE THE BACTERIAL LOAD SO THAT THE BODIES INNATE CAPACITY TO HEAL, CAN BE MORE SUCCESSFUL SOLVE THAT MIGHT SOUND LIKE A SUBTLE SHIFT BUT IT'S IMPORTANT IN HOW WE THINK. THE PARADIGM AND THE LENS WHICH WE LOOK AND PARALLEL TO ARE WE FIGHTING CANCER AND ENABLING THE HOST AND THE INNATE MY NEXT LIFETIME I WANT TO BE ANNAN THROW POLL GIST. SO TO REFLECT ON THE LANGUAGE WE USE IN MEDICINE AND SCIENCE AND WHAT DOES IT TELL US ABOUT OUR PARADIGM? IT'S VERY TELLING AND ANTI EVERYTHING AND YOU HAVE A PROBLEM AND I HAVE AN ANTI, RIGHT. WE HAVE ANTIBIOTIC. YOU HAVE DEPRESSION AND I HAVE AN ANTI A PARADIGM COMES BACK TO THIS REDUCE IS TICK, HERE IS THE FIND IT AND THE FIX IT AND IF IT WERE THAT SIMPLE, IF THAT WERE SUCCEEDING, THERE'S NOTHING INNATELY WRONG IT'S JUST INSUFFICIENT. AND THE LANGUAGE HELPS US RECOGNIZE WE'RE LOOKING THROUGH THE LENS. THE QUESTION OF, IS THERE AN INNATE CAPACITY TO HEAL? SOMETIMES THIS QUESTION TRIGGERS PEOPLE BECAUSE THERE'S IT COULD SAY IF DO YOU ANYTHING RIGHT, YOU WILL NEVER GET SICK OR DIE AND OBVIOUSLY IT'S NOT TRUE. WE'RE ALL MORTAL BEINGS AND WE'RE GOING TO GET SICK AND DIE. IT'S NOT LIKE IF YOU DO IT ALL RIGHT AND ARE WE DESIGNED AS HUMAN BEINGS WITH INNATE CAPACITY TO HEAL. SIMPLE THINGS LIKE CUTS. IF YOU REALLY THINK ABOUT IT AND WE BECOME SO ACCUSTOMED TO WELL, I GOT A CUT AND IT HEALED. WE FORGET HOW AMAZING IT IS AND HOW MANY MECHANISMS ARE IN PLAY FOR THE BODY TO ACTUALLY HEAL A CUT. A BROKEN BONE. EVEN MORE SIGNIFICANT IF IT'S ALIGNED AND NOT OUT OF ALIGNMENT OR COMPLEX BREAK, LEAVE IT ALONE. THE BODY HAS THE CAPACITY TO HEAL THE BONE. I MEAN, AGAIN, IF WE PAUSE AND THINK ABOUT HOW AMAZING THAT IS, IT'S SIGNIFICANT. AND WHAT ABOUT AT THE MOLECULAR LEVEL IT'S AMAZING WHEN YOU THINK ABOUT, THERE'S TRANSFER RNA AND THERE ARE ALL OF THESE MOLECULES THAT ARE DESIGNED TO HELP FIND ERRORS IN A MOM MOLECR LEVEL AND CORRECT THEM, SIMPLY PUT. PULLING BACK AND SAYING, WHAT IF WE LOOK THROUGH OUR CLINICAL APPROACHES AND OUR RESEARCH APPROACHES, JUST AS THE GENTLEMAN WHO WON THE NOBEL PRIZES, WHAT IF WE LOOK THROUGH THE LENS OF HOW CAN WE OPTIMIZE THAT CAPACITY TO HEAL? HOW CAN WE, ANOTHER WAY TO SAY THAT, HOW CAN WE ACTIVATE A HEALING RESPONSE? AND IN MY CONCEPT OF AK TA RATE TA RATEISED HEALING, AK TA RATEA HEALING RESPONSE IS PLACEBOS. THE ONLY THING I WANT TO BRING UP IN THIS CONTEXT IS WHEN I BACK IN THE DARK AGES WHEN I WAS IN TRAINING, PLACEBOS WAS A THING TO TRICK PATIENTS TO SEE IF THE REAL INTERVENTIONS WORKS AND THE REFRAME IS, WOW, THINK ABOUT A REAL PLACEBO EFFECT? THE FACT THAT THERE COULD BE SOMETHING LIKE A PLACEBO PILL, OR A DIFFERENT INTERVENTION THAT THEN AK TA VISITS THE MIND TO HEAL WITHOUT AN ACTIVE AGENT. WE SHOULD BE FIGURING OUT HOW TO DO THAT MORE CONSISTENTLY AND THAT IN MY OPINION SHOULD BE ONE OF OUR QUESTS RIGHT. IT'S A GREAT ILLUSTRATIONS OF THE BODY'S INNATE CAPACITY TO HEAL. HOW WE DO THE RESEARCH AND WHAT IF WE CHANGE THE LENS THROUGH WHICH WE LOOK. NEXT SLIDE, PLEASE. I HAVE A COUPLE OF QUOTES SPRINKLES IN HERE BECAUSE I LOVE THESE. DAVID BOR STEEN, NOT SOMEONE I KNOW, HE WAS WITH A LIBRARY OF CONGRESS BUT THE GREATEST BARRIER TO DISCOVERY IS NOT IGNORANCE, BUT THE ILLUSION OF KNOWLEDGE. NOW I'M GOING TO READ THAT AGAIN BECAUSE PARTICULARLY THE RESEARCH. WHEN WE GET CAUGHT IN OUR OWN WAY OF THINKING ABOUT THINGS, IT'S REALLY RELATED TO THE FIRST QUOTE, RIGHT, THAT WE CAN'T SOLVE PROBLEMS WITH THE SAME THOUGHT PROCESS THAT GOT US INTO THE CIRCUMSTANCES WE'RE IN. SO, I WOULD ENCOURAGE YOU TODAY AND TOMORROW, TO REALLY STAY OPEN AND BE AWARE OF PERHAPS YOUR OWN ILLUSION OF KNOWLEDGE IN CERTAIN AREAS AND WHAT MIGHT HAPPEN IF YOU STEP OUT OF THAT. SO THIS IS INTERESTING. A LOT OF MY WORK IS IN THE TRANSFORMATION OF HEALTH SYSTEMS AND WHEN PEOPLE USE THE CONCEPT OF TRANSFORMATION A LOT, I THINK WE OVERUSE TRANSFORMATION. A LOT OF WHAT WE CALL TRANSFORMATION IS SIMPLY I WOULD CALL IMPROVEMENT, CONTINUOUS IMPROVEMENT OF THE CURRENT SYSTEM. BUT WHAT MAKES SOMETHING TRANSFORMATIONAL IN MY OPINION IS WHEN THE IF YOU WERE OF THE SYSTEM HAS CHANGED AND THIS PARALLELS THE RESEARCH, SO I WOULD SAY THAT IT SIMPLIFIED THE PRIMARY PURPOSE OF OUR CURRENT SYSTEM TO CURE IT WHEN WE CAN AND WHEN WE CAN'T CURE IT, MANAGE IT. I THINK THAT SIMPLY PUT IS THE DOMINANT PARADIGM OF OUR CURRENT SYSTEM AND WHEN WE TALK ABOUT WHOLE HEALTH AND YOU CAN GO TO THE NEXT SLIDE, WHAT DO WE MEAN BY WHOLE HEALTH. I THINK THAT THE PURPOSE OF WHOLE HEALTH VERY DIFFERENT PURPOSE, THAN THE PURPOSE OF THE HEALTH, THE DOMINANT HEALTH SYSTEM WE DESCRIBED. IT'S TO EMPOWER AND EQUIP. THOSE ARE TWO DIFFERENT ELEMENTS THAT ARE BOTH CRITICALLY IMPORTANT. EMPOWER PEOPLE AND THEN WHEN EMPOWERED, EQUIP THEM WITH THE SKILLS THAT THEY NEED AND THE SUPPORT THEY NEED SO THAT THEY CAN TAKE CHARGE OF THEIR PHYSICAL, MENTAL AND SPIRITUAL HEALTH FOR WHAT PURPOSE? SO THEY CAN LIVE A FULL AND MEANINGFUL LIFE. WHATEVER IS THAT MEANS FOR THEM. AND THIS DOESN'T -- LOTS OF TIME PEOPLE THINK WHOLE HEALTH IS PREVENTION. IT'S NOT. PREVENTION IS AN IMPORTANT PIECE OF THIS BUT WHOLE HEALTH, THIS IS APPLICABLE AND THE LAST FEW DAYS OF LIFE AS IT IS AT THE BEGINNING OF HEALTH. I'M EMPHASIZING THIS BECAUSE AS YOU GO THROUGH THE NEXT TWO DAYS AND YOU ARE ENTERTAINING, WHAT DOES THIS MEAN FOR PAIN AND PAIN MANAGEMENT AND THE RESEARCH THAT WE'RE ADVANCING. IF THIS IS THE PARADIGM AND TO EMPOWER PEOPLE AND EQUIP PEOPLE TO TAKE CHARGE OF ALL ASPECTS OF THEIR HEALTH FOR THE INTENTION AND PURPOSE OF LIVING THEIR FULL TIME YOUR QUESTION AND RESEARCH CHANGED DRAMATICALLY AND NEXT SLIDE. THIS IS GREAT. NO INTENT SHOULD BE MADE TO CURE THE WE'D WITHOUT THE SOUL. LET NO ONE PERSUADE YOU TO CURE CURE THE HEAD UNTIL HE HAS GIVEN HIS SOUL TO BE CURED. THIS IS THE GREATER OR OF OUR DAY. IT'S A LITTLE DISCOURAGING THAT WAS THE GREATER OR OF THE DAY WHEN PLATEAU WAS ALIVE BECAUSE I WOULD SAY IT'S ONE OF THE GREATERRGREAT ERRORSOF THE DAY . SO VERY SIMPLY PUT, I REFERENCED REDUCTIONISTIC APPROACH AND SYSTEMS APPROACH AND WHEN I THINK WE'VE COME FROM A REDUCTIONISTIC PARADIGM AND I HOPE WE'RE MOVING INTO A SYSTEMS APPROACH AND WHAT DO WE MEAN BY THAT CONCRETELY? IT'S OFTEN REACTION TIVE AND WE WAIT WELL THERE'S A PROBLEM AND WE RESPOND. SPORADIC INTERVENTIONS AND BIOMEDICAL INTERVENTIONS AND WE LET THE INDIVIDUAL ON THEIR OWN TO HOPEFULLY ENACT THE RECOMMENDATIONS. WINDOW DOES A SYSTEM APPROACH LOOK LIKE? WELL, WE'RE FOCUSED ON THE PERSON AND THEIR SENSE OF MEANING AND PURPOSE IN THEIR LIFE. IT'S NOT JUST ADDRESSING THE PROBLEMS, IT'S HELPING PEOPLE REALIZE THAT THEIR ASPIRATION AND HOW THEY CAN PARTNER WITH THE TEAM TO REALIZE THAT IN THEIR LIFE. IT'S MUCH MORE LIFE-FOCUSED THAN PROBLEM FOCUSED. IT'S NOT ONLY MANAGING DISEASE BUT OPTIMIZING HEALTH AND IT'S NOT ONLY FINDING AND FIXING PROBLEMS BUT IDENTIFYING THE RISK AND MINIMIZING IT. MUCH MORE PROACTIVE ACROSS THE LIFESPAN AND ENGAGING WHOLE HEALTH APPROACHES AND I'LL SHOW YOU A GRAPHIC OF HOW WE THINK ABOUT THAT IN A MOMENT AND VERY IMPORTANTLY, NOT SAYING, HAVE AT IT, HOPE IT TURNS OUT WELL, LET'S SEE HOW IT GOES. REALLY ADDRESSING THE SKILL BUILDING AND THE SUPPORT THAT PEOPLE NEED. NOT ONLY IN THE HEALTH-CARE SYSTEM BUT WHERE THEY WORK AND WHERE THEY LIVE TO REALLY HELP THEM OWN THEIR SELF-CARE AND THEIR PART OF THE HEALING PROCESS. NEXT SLIDE. MANY PEOPLE HAVE VERY SIMILAR GRAPHICS. THIS IS EVOLVED FROM DUKE TO THE V.A. TO THE HEALTH INSTITUTE. YOU CAN SEE THAT THE ELEMENTS HERE, THE CARE TEAM AND THE CLINICAL PIECE IS ONE PIECE THAT A PRETTY -- ONE PIECE OF A WHOLE WHERE WE START FIRST WITH THE PERSON THEMSELVES AND WHAT MATTERS MOST TO THEM. THAT'S A REAL SHIFT. AND YOU CAN SEE THAT IN THE PAIN COMMUNITY AND I'LL TALK MORE ABOUT THAT IN A MOMENT. THE MIDDLE CIRCLE, THE SELF-CARE CIRCLE ARE DIFFERENT DIFFERENT ELEMENTS OF SELF-CARE. MOST OF US ADDRESS VERY, VERY SIMILAR ASPECTS AND WE MIGHT LABEL THEM DIFFERENTLY BUT OF COURSE IT'S THINGS LIKE NUTRITION AND MOVING YOUR BODY AND ALSO THE POWER OF YOUR MIND AND SPIRITUALITY AND YOUR RELATIONSHIPS AND YOUR SLEEP, ALL OF THESE ASPECTS EFFECT PEOPLE PARTICULARLY WHEN DEALING WITH COMPLEX CHRONIC ISSUES LIKE PAIN. SO, THIS IS KIND OF THE VISION OF, WELL, THIS IS WHOLE HEALTH. IT STARTS WITH THE INDIVIDUAL AND THEIR PURPOSE AND A BIG EMPHASIS ON SELF-CARE. YES THE CARE TEAM AND YES IN COMMUNITIES BUT HOW DO YOU ACTUALLY OPERATIONALIZE THAT BECAUSE IF WE'RE GOING TO RESEARCH THAT, WE HAVE TO HAVE A SYSTEM AND APPROACH THAT SAY OK, WELL THAT LOOKS NICE AND CONCEPT AND THEORY, HOW DO YOU ACTUALLY MAKE IT HAPPEN? SO NEXT SLIDE. LET'S THE QUESTION I JUST ASKED, YOU CAN ADVANCE. SO THIS IS OUT OF THE WORK IN THE V.A. WHICH IS ON GOING AND QUITE AMAZING UNDER THE LEADERSHIP OF Dr. KIGLER AND WE REALIZE THROUGH A LOT OF WORK IN THE FACILITIES AND WITH CLINICIANS AND RESEARCHERS ACROSS THE NATION, THAT THIS IS NOT ALL DONE IN THE CLINICAL ENVIRONMENT IDEALLY THAT THE CLINICAL ENVIRONMENT IS INCREDIBLY IMPORTANT BUT THIS QUESTION OF HELPING PEOPLE UNDERSTAND WHAT MATTERS TO THEM AND ENGAGING THEM IN THEIR HEALTH IS A HUGE ISSUE THAT THE HEALTH SYSTEM ISN'T DESIGNED TO DO SO THE ABILITY TO USE PEER PROGRAMS TO HELP EXPLORE THESE NON CLINICAL QUESTIONS OF WHAT MATTERS MOST TO YOU, WHAT DO YOU WANT YOUR HEALTH FOR, THAT EMPOWER PIECE IS IT DOESN'T TAKE A CLINICAL TEAM IT'S SKILL-BUILDING AND SUPPORT AND WHEN THESE ARE ALIGNED AND PEOPLE ARE CONNECTED WITH EACH OTHER, THIS CAN HAVE AMAZING IMPACT. SO I'LL GO THROUGH THESE BRIEFLY. THE EMPOWER PIECE, AS I MENTIONED, IS ABOUT HELPING PEOPLE FIND WHAT MATTERS MOST TO THEM IN THEIR LIFE AND GIVE THEM A SENSE OF HOPE AND THERE'S A REASON TO ENGAGE IN THEIR LIFE AGAIN. AND THIS IS BEST LED BY PEERS IN OUR EXPERIENCE AND THE V.A. HAS GREAT MATERIALS AND COURSES THAT ARE OPEN SOURCE AND AVAILABLE TO ALL. MOVED YOUR BODY AND YOU NEED TO KNOW HOW TO DO IT DIFFERENTLY AND SUPPORT FOR REALLY ENGAGING AND BEHAVIOR CHANGE SO THE GREAT THINGS ABOUT THIS IS THESE SELF-CARE APPROACHES ARE CONSISTENT ACROSS BECAUSE AGAIN THE PARADIGM IS DIFFERENT AND WE'RE OPTIMIZING THE BODY'S ABILITY TO HEAL AND SO WE OPTIMIZE SELF-CARE AND IT'S THE SAME WITH A FEW TWEAKS WHETHER WHATEVER YOUR CONDITIONS IS AND THIS IS DONE THROUGH INSTRUCTORS AND COACHES AND ACROSS THIS DIFFERENT AREA AND NEXT SLIDE. IT MAKES A HUGE DIFFERENCE WHEN THE CLINICIANS ARE UNDERSTANDING THE CONCEPT OF THIS PARADIGM AND SUPPORT IT AND I'LL JUST TELL YOU A GREAT ILLUSTRATION OF THAT APPROACH FROM THE V.A. IN LITTLE ROCK. AND THE CARE TEAM, THIS IS MY STORY SO IF I GET IT WRONG I APOLOGIZE. THE CARE TEAM, AS I UNDERSTAND, WAS NOT REAL EXCITED ABOUT THIS NEW APPROACH AND REALLY LIKE THEY HAVE ENOUGH ON THEIR PLATES AND THEY'RE OVERWHELMED AND SO WHAT THEY DID AND THEY CREATED THE SELF-CARE PROGRAM TO WORK WITH THE CLINICIANS AND THE PAIN PATIENTS GOT SO ENGAGE FROM THEIR OWN LIFE AND HEALTH AND WERE GETTING THE OPPORTUNITY TO ENGAGE WORKPLACES IS A HUGE OPPORTUNITY THAT WILL SAVE FOR ANOTHER TALK. AND NEXT SLIDE. SO DOES IT WORK ANY WANT TO HIGHLIGHT A BIT OF THE RESEARCH AND THERE WAS AN ARTICLE PUBLISHED CAN YOU GO TO THE NEXT SLIDE FROM ALL THE V.A. WORK WHICH THIS IS JUST THE SUMMATION BUT I THINK WE'RE TALKING ABOUT PAIN AND I DID WANT TO HIGHLIGHT THAT WHOLE HEALTH HAD A POSITIVE IMPACT ON REDUCING OPIOID USE AND IN THE VETERANS USING WHOLE HEALTH AND THOSE WITHIN A THREEFOLD REDUCTION IN THOSE PATIENTS WHO ARE USING WHOLE HEALTH APPROACHES VERSUS THOSE WHO WERE NOT AND LOTS OF OTHER BENEFITS FROM THIS APPROACH INCLUDING THIS IS THE GRAPHIC AND YOU CAN SEE THERE'S A DOSE RESPONSE CURVE AND BETWEEN OPEN REDUCTION AND THE DIFFERENT LEVELS OF WHOLE HEALTH APPROACHES SO THEY'RE DEFINED ON THE SIDE AND THE INTENSIVE AND MIDDLE GROWN POWER IS COMPREHENSIVE INTEGRATION TIVE APPROACH ONLY AND THE CORE WHOLE HEALTH INTENSE AND CORE INCLUDES THE PEER PIECE AND THE SUPPORT AND THE COMPREHENSIVE INCLUDES BOTH SO VERY INTERESTING DATA. AND I'M NOT GOING TO GO INTO DEPTH ON THIS BUFFET TALK ON THIS LATER AND THIS IS WORK WITH A SIGNIFICANT REDUCTION OF SPINE PROCEDURES WITH VETERANS USING WHOLE HEALTH VERSUS THOSE WHO ARE NOT AND JUST TO LET YOUR APPETITE THAT THIS ISN'T JUST GREAT IDEAS, THERE'S REAL OUTCOMES AND HAVING LOOKED AT THE DATA LIKE THAT, I SHARE THIS SLIDE OFTEN AND I THINK ONE OF THE THINGS THAT WE'RE HERE TO REALIZE IS THAT IT'S SO MUCH MORE THAN JUST HOW MANY OWNERSHIPS ARE TAKEN ALTHOUGH IT'S CRITICAL AND HOW MANY PROCEDURES ARE DONE. THIS IS ABOUT PEOPLE'S LIVES. THIS IS WHAT CHANGES WITH THIS PARADIGM AND I WILL TAKE A MOMENT TO READ THESE. THESE NOT SPECIFIC TO PAIN PATIENTS BUT THEY'RE THREE PATIENTS WHO WE'RE NOT HAND SELECTED OUT OF THE NATION AND THE TOP IS THE 52-YEAR-OLD GENTLEMAN AND IT'S A GOOD THE CHANGE IN THIS APPROACH, THE CHANGE IN THIS LENS AND PAUL HEALTH HE SAYS BEGAN BY JOURNEY TO JOY AND WHO SAYS IT WILL A BEGAN BY I'M A CHANGE PERSON AND NO LONGER NEED MY CANE. SO THERE ARE CLINICAL IMPACT AND THE WHOLE HEALTH GROUP HAS BECOME MY FAMILY. MY NEUROLOGY DOESN'T NEED TO SEE ME. YES, GREAT CLINICAL OUTCOMES. AND 71-YEAR-OLD GENTLEMAN, I HAVE LOST 33 POUNDS, I GO TO FIT CLASS WHICH IS A MOVEMENT CLASS, NUTRITION CLASS, BATTLED FIELD, ACUPUNCTURE. MY WIFE SAYS, I HAVE A POSITIVE ATTITUDE NOW. [LAUGHTER] I LOVE IT SO MUCH. AND MY DIABETES IS UNDER CONTROL AND MY BLOOD PRESSURE IS DOWN AND MY LIPIDS ARE GOOD AND I SEE MY PRIMARY CARE DOCTOR MUCH LESS. AND A 37-YEAR-OLD WOMAN, I USED TO DRIVE OVER THE MISSISSIPPI RIVER BRIDGE TO THE JEFFERSON V.A. AND THINK ABOUT JUMPING EVERY TIME. I WANT TO SHARE WITH YOU AS YOU ASK YOURSELF THOSE QUESTIONS. WHAT DOES IT LOOK LIKE WHEN YOU APPROACH IT FROM A REDUCTIONISTIC PARADIGM AND WHAT CHANGES WHEN YOU THINK ABOUT IT THROUGH A SYSTEMS' LENS. I WOULD ENCOURAGE YOU TO REMEMBER THAT WHAT MATTERS MOST TO US, AS CLINICIANS, AND WHAT MATTERS MOST TO US AS RESEARCHERS, MAYBE NOT BE WHAT MATTERS MOST TO THE PERSON. AND I WANT TO SHARE A STORY ACTUALLY THAT Dr. TOM INSUL THE FORMER DIRECTOR OF NIMH AND SHARED IN A BOOK AND I'LL PARAPHRASE HIS STORY BUT IT'S REALLY SIGNIFICANT AND HE WAS TALKING ABOUT HOW HE WAS SOMEWHERE GIVING A COMMUNITY LECTURE ON ALL OF THE GREAT WORK, THIS IS WHEN HE WAS STILL WITH THE NIH. ALL THE OF THE GREAT ADVANCES OF THE RESEARCH OF NIMH AROUND MENTAL HEALTH AND HOW AMAZING THEIR ADVANCES ARE AND WHAT THEY WERE LEARNING AND VERY PROUD OF THIS AMAZING WORK AS HE SHOULD HAVE BEEN. FROM RACE ITSING AND WHEN IT WENT AND HE WAS THE FIRST ONE AT THE MICROPHONE AND SCHEER WHAT THAT MEAN SAID TO HIM. YOU REALLY DON'T GET IT. MY 23-YEAR-OLD SON HAS SCHIZOPHRENIA. HE IS HOSPITALIZED FIVE TIMES AND HAS MADE THREE SUICIDE ATTEMPTS AND HE IS NOW HOMELESS. OUR HOUSE IS ON FIRE. OUR HOUSE IS ON FIRE AND YOU ARE TALKING ABOUT THE CHEM IS TEE OF THE PAINT. WHAT ARE YOU GOING TO DO TO PUT OUT THIS FIRE? I THINK IT'S SUCH A POIGNANT QUESTION. I THINK THAT'S THE CHALLENGE FOR US AS WE THINK ABOUT THIS IN THE CONTEXT OF PAIN. THE REDUCTIONISTIC RESEARCH IS CRITICALLY IMPORTANT BUT IT'S NOT ENOUGH. SO WHAT CAN WE DO AND WHAT CHANGES? WHAT IS POSSIBLE WHEN WE LOOK AT PAIN AND PAIN MANAGEMENT THROUGH THIS DIFFERENT LENS. I THINK FIRST OF ALL WE'LL ASK DIFFERENT QUESTIONS AND SECOND OF ALL WE ARE GOING TO SEE AND EXPLORE NEW POSSIBILITIES THAT WE OTHERWISE JUST WOULD NOT SEE BECAUSE WE'RE LOOKING THROUGH A DIFFERENT LENS. SO NEXT SLIDE, PLEASE. I'M SURE MANY OF YOU KNOW HIS WRITING. WE HAVE BEEN WRONG ABOUT WHAT OUR JOB IS IN MEDICINE. WE THINK OUR JOB IS TO ENSURE HEALTH AND SURVIVAL BUT REALLY, IT'S LARGER THAN THAT. IT'S TO ENABLE WELLBEING AND WELLBEING IS ABOUT THE REASONS ONE WISHES TO BE ALIVE. I LOVE THAT. WELLBEING IS ABOUT THE REASONS ONE WISHES TO BE A LIVE AND THOSE REASONS MATTER NOT JUST AT THE END-OF-LIFE, OR WHEN DISABILITY COMES, BUT ALL ALONG THE WAY. NEXT SLIDE. AND THE COST DECREASE SO IT'S NOT AS IF WE'RE ABANDONING WHAT THE OUTCOMES THAT WE NEED. IT'S QUITE THE OPPOSITE. IT'S THAT DOING MORE OF THE SAME ISN'T GETTING US WHERE WE NEED TO BE. AND IN THIS WAY, WE CAN. SO, IN CONCLUSION, I THINK THAT'S MY LAST SLIDE, I JUST WANTED TO SAY TO YOU ALL BEFORE WE MOVED TO Q&A THAT I THINK THAT YOU ALL HAVE A TREMENDOUS OPPORTUNITY TO LEAD THE NATION IN AN ENTIRELY NEW APPROACH TO THINKING, TO TRAITING, AND TO RESEARCHING THE ISSUES AROUND PAIN. AND I THINK THAT THE NUMBER OF LIVES THAT YOU CAN IMPACT, THE AMOUNT OF SUFFERING THAT YOU CAN SOOTHE IS PHENOMENAL. REALLY IT'S PHENOMENAL AND I WANT TO A EMPLOYED THE ENTIRE COMMITTEE AND THE ENTIRETY OF NIH AND THE COP AGO RACE THAT HAS FOCUSED AND TAKEN COURAGE, IN MY OPINION, TO MAKE THIS WITH THAT I'LL TURN IT OVER TO Q&A. >> THANK YOU. THANK YOU SO MUCH Dr. GAUDET. THIS WAS EXCELLENT AND SO NEEDED FOR THE FACE. YOU REALLY SET UP THE SPACE FORT NEXT TWO DAYS. SO WE GOT QUESTIONS FROM THE AUDIENCE AND I'D LIKE TO BRING A COUPLE TO YOUR ATTENTION. THE FIRST QUESTION, WHOLE HEALTH IS LIMITED TO PATIENTS WHO HAVE BEEN AT A CARE FACILITY AND CONSTRUCT REQUCONNED BY PATIENTN SPECIALISTS. >> SO, I'M SORRY, SO THE QUESTION IS -- >> THE WHOLE APPROACH IS IT APPLICABLE OR A CARE FACILITIES OR OUT PATIENT? >> THANK YOU. THANK YOU FOR THE SUMMARY OF THAT, I APPRECIATE THAT. NO, ABSOLUTELY. IT IS VERY INTERESTING THAT IT IS APPLICABLE ACROSS ALL SEVERITY OF WHETHER IT'S PAIN OR OTHER CONDITIONS AND ACROSS SETTINGS SO IN A LARGE DEGREE, BECAUSE SO MUCH OF THIS IS NOT JUST CLINICAL, IT'S VERY, VERY ADAPTABLE AND OFTEN OPTIMAL, EVEN THE EXAMPLE I GAVE LIKE THE LITTLE ROCK CLINIC WHERE THERE WAS WELL BEING WHOLE HEALTH, YOU KNOW, SELF-CARE APPROACH AND IN COLLABORATION WITH THE CLINICAL SO IT'S NOT IN ANYWAY LIMITED TO INPATIENT AND IT'S OFTEN MOST EFFECTIVE IN THE COMMUNITIES AND IN THE PLACE WHERE PEOPLE LIVE. >> GREAT. THANK YOU. TO WHAT DEGREE THIS APPROACH USE COMPARED TO CONSCIOUS PRESENTED UP FRONT IS THERE EVIDENCE THAT THEY IMPROVE HEALTH OUTCOMES AND COSTS AT THE POPULATION LEVEL? >> SO, I WISH I WERE MORE OF AN EXPERT ON THE POPULATION SIDE OF THIS BECAUSE THOSE ARE TREMENDOUSLY IMPORTANT QUESTIONS AND I DO THINK THAT WHAT WE WERE SEEING -- ONE OF THE THINGS I VALUE ABOUT THIS V.A. WORK, MANY THINGS, THAT YOU KNOW THERE'S BEEN, LET'S SAY 20 YEARS AGO, A PRESUMPTION THAT THESE KINDS OF PHILOSOPHIES AND APPROACHES WERE FOR PEOPLE WHO WERE PRIVILEGED. LIKE PEOPLE WHO HAD ACCESS AND HAD AVAILABILITY AND SERVICES AND HAD BEEN QUITE HONESTLY PEOPLE HAD THE PERCEPTION THAT WELL, SURE, THAT'S GREAT TO THINK ABOUT. YOUR SENSE OF MEANING AND PURPOSE IN YOUR LIFE IF YOU ARE AFFLUENT AND YOU CAN DO THAT. WELL, WHAT IS SHOWN OVER THE LAST 10 YEARS OR SO THIS IS EVERY BIT IS APPLICABLE IF NOT MORE FOR THE HOMELESS POPULATION, FOR PEOPLE WHO ARE JUST TRYING TO GET THROUGH THE DAY THAT ACTUALLY, AND AGAIN, USING THE V.A., EXPERIENCE, WHEN THIS APPROACH WAS OPEN TO ALL VETERANS AND THE PRIMARY PEOPLE COMING WERE PEOPLE STRUGGLING WITH MENTAL HEALTH AND OR PAIN. YOU KNOW, ACROSS THE NATION. SO I THINK THE IMPACT AT THE POPULATION LEVEL IS SIGNIFICANT. I THINK IT'S ACTUALLY MORE OF A POPULATION BASED APPROACH AND A MOVEMENT IF YOU WILL. THIS IS OUT OF THE SCOPE FOR THIS MEETING TODAY AND TOMORROW I WOULD LIKE TO SEE THE DAY WHERE THIS APPROACHES TO EMBRACE WHOLE HEALTH. WHAT LINES OF EFFORT SHOULD WE PRIORITIZE TO KEEP THING HEADED IN THE RIGHT DIRECTION? >> I ACTUALLY THINK THE CRISIS IS A GOOD THING FOR THIS TRANSFORMATION, RIGHT. BECAUSE, LIKE WE STARTED AT THE BEGINNING, WHAT WE'RE DOING IS NOT WORKING AND IT'S EXPENSIVE AND WE CAN'T SUSTAIN IT. THE NATION CANNOT SUSTAIN THAT LEVEL OF EXPENDITURES FOR HEALTHCARE. WE WILL FAIL TO BE COMPETITIVE AND THE GLOBAL MARKETS. I MEAN, IT'S JUST NOT SUSTAINABLE SO THAT CREATES A PRESSURE THAT I THINK IS GOOD FOR US TO DRIVE TO WHOLE HEALTH BECAUSE THE GREAT THING IS, YOU KNOW, A LOT OF PEOPLE, WHEN THEY START TO SEE THE DATA THAT OH, OUTCOMES ARE BETTER AND COST DECREASE. WHAT DO WE NOT LIKE ABOUT THAT? THAT'S FABULOUS. THE CHALLENGE THAT WE HAVE IS THE PAYMENT SYSTEM HAS TO CATCH UP, RIGHT. SO AS LONG AS WE STILL HAVE FEE FOR SERVICE PAYMENTS, WHERE THERE'S PAIN CLINICS AND THEY'RE GETTING PAID FOR THEIR INTERVENTIONS AND NOT FOR ANY OF THIS, IT'S NOT SUSTAINABLE. THE GOOD NEWS IS AND I DON'T MEAN TO MAKE IT SIMPLE. IT'S COMPLEX AND DIFFICULT OR IT WOULD HAVE ALREADY HAPPENED. THE GOOD NEWS IS AS WE SHIFT MORE IN THIS NATION TO VALUE-BASED PAYMENTS, THAT WILL DRIVE THE NEED FOR VALUE-BASED CARE, RIGHT. SO, VALUE BASED PAYMENT WHERE WE'RE PAYING FOR OUTCOMES, NOW INCENTIVIZES SYSTEMS TO SAY OH I NEED THAT WHOLE HEALTH APPROACH ACTUALLY. WE'RE NOT GOING TO SUCCEED IF WE DON'T HAVE A APPROACH THAT ADDRESSES HEALTH AND WELLBEING AND EVERYTHING WE HAVE RIGHT NOW, IS FEE FOR SERVICE BASED SO THE PAYMENT AND THE POLICY SIDE OF ALL OF THIS IS CRITICAL. >> THANK YOU. DO YOU CONSIDER THE WHOLE HEALTH FRAMEWORK AS CONSISTENT WITH THE SOCIAL MODEL OR FUNDAMENTALLY DIFFERENT IN IMPORTANT WAYS? >> GREAT QUESTION. AND I THINK THIS IS VERY, VERY CONSISTENT WITH THE BY OWE BIO-L MODEL. THE BIG SHIFT IN THIS APPROACH IS ACTUALLY WHAT I WOULD SAY STARTING FROM A DIFFERENT PLACE SO CAN YOU DO A SHIFT OF A MODEL OR HOLE IS TICK APPROACH AND NOT SHIFT IS THAT PARADIGM AND I HAVE FOUND AND I THINK THE RESEARCH IS BEARING OUT, THAT THAT SHIFT IS CRITICAL AND THERE ARE MANY OF THESE CIRCUMSTANCES AND OFFERINGS AT AVAILABLE TO PEOPLE AND THEY'RE GOING TO TAKE ADVANTAGE OF IT. THE REAL SHIFT IS USING ALL THE TOOLS AND APPROACH AND BIO PSYCHOSOCIAL MODEL THAT'S IT BUT STARTING FROM A THE QUESTIONS WE DON'T ASK OURSELVES CANCER DIAGNOSIS BUT WHAT BUT ALIGNING THOSE APPROACH THAT PERSON CAN HAVE A MORE FULFILLING LIFE AND THEN IT'S OH, BY THE WAY, THEIR PAIN SCORES COME DOWN AND THE BIG SHIFT AND ALL THAT HAVE IS. >> HOW CAN WE MAKE THEM OPTION IN THE PROGRAMS AND ASSESS IS STILL TOO LOW. >> THE LAST PART, I'M SORRY, MY AUDIO IS NOT GREAT. >> SO, I'M STRUGGLE TO GO HEAR JUST A LITTLE BIT, I APOLOGIZE. >> NO PROBLEM. THE QUESTION OF HOW WE CAN MAKE NON DRUG OPTION FORCE PAIN MORE AVAILABLE BECAUSE THE NUMBERS OF THOSE WHO CAN ASSESS THE IS STILL VERY LOW. >> IT IS LOWER THAN IT NEEDS TO BE. THE V.A. HAS MADE ADVANCES BECAUSE THEY HAVE GOTTEN REGULATIONS CHANGED SO THESE APPROACHES ARE INCLUDED IN THE MEDICAL BENEFITS PACKAGE FOR VETERANS AND IT'S CLINICALLY INDICATE AND CERTAINLY PAIN PATIENTS IT WOULD BE. SO THAT IS A HUGE STEP AND THE ONLY REASON I'M REFERENCING THAT AS THE V.A. SHIFTS AND THE SERVICES ARE COVERED AND WE'RE ON THE RIGHT PATH, IT'S TOO SLOW FOR SURE, BUT WE'RE ON THE RIGHT PATH WE GET MORE OF THE DATA THAT CAN SUPPORT THIS MORE BROADLY A CROSS THE NATION SO I THINK WE'RE ON THE RIGHT PATH OF THE INCLUSION OF THOSE APPROACHES IN THE MEDICAL BENEFITS PACKAGE AND IT WAS A HUGE STEP FORWARD AND THE ABILITY TO ALSO FOR VETERANS TO GET THE APPROACHES IN THE COMMUNITY NOT JUST ONLY THROUGH THE V.A. IS A HUGE ADVANCE AS WELL AND AS EVERYBODY KNOWS, THE V.A. IS A CHALLENGING BUREAUCRACY TO WORK THROUGH AND HOPEFULLY IT CAN LEAD THEM THE NATION SAYING LOOK THIS IS EFFECTIVE WHY IS IT NOT AVAILABLE TO ALL PEOPLE? >> >> SO OUR HEALTH-CARE SYSTEM WAS EXCEPTION OF THE V.A. AND MAYBE KAISER. FOCUS ON PROCESS RATHER THAN COST SAVINGS. IT SEEMS THE WHOLE CARE WILL PRIOR PARADIGM SHAPE INCLUDING WIDESPREAD HEALTHCARE QUALITY CHANGES. DO YOU HAVE AN IDEA ON HOW BEST WE, AS RESEARCHERS, CAN ASSIST IN MOVING THAT NEEDLE? >> THAT IS A GREAT QUESTION. I WOULD LOVE YOU ALL TO TELL ME. [LAUGHTER] BECAUSE I TOTAL TOTE TOTALLY AGF WE DON'T ADVANCE HEALTH SECTOR OF FINANCE AND POLICY, WE CAN COME UP, AS YOU ALL KNOW, WE CAN CAN COME UP WITH THE RESEARCH AND DATA THEY'RE EFFECTIVE BUT THEY WON'T BE EFFECTIVE. SO I TOTALLY CONCUR THAT THE POLICY SIDE, THE FINANCE POLICY IS ABSOLUTELY PIVOTAL TO THIS ACTUALLY GOING FROM THE RESEARCH TO REAL IMPLEMENTATION CONNECTING PEOPLE'S LIVES AND I THINK IT'S A GREAT QUESTION THAT I WOULD KIND OF THROWBACK AT THE GROUP THE NIH CAN PLAY IN ADVANCING THE CONVERSATION AROUND POLICY CHANGE. I ALSO DO THINK IT'S A PLACE WHERE -- AT THE PANDEMIC, HAS HELPED TO SOME DEGREE THAT WE ARE RETHINKING HOW DO WE DELIVER HEALTHCARE AND ADDRESS THE POLICY SIDE OF THIS SO THERE'S AN OPENING AND IT'S HARD AND COMPLICATED. >> THANK YOU. CAN YOU DISCUSS HOW YOU DETERMINE THE DOSE OF EACH COMPONENT FROM THE COMPONENT APPROACHES SO THAT YOU UNDERSTAND WHAT IS THE EFFECT? >> AH! THAT'S A GRAY QUESTION TO END ON. BECAUSE I FAILED TO EXPLAIN, AND THIS IS A REALLY IMPORTANT THING, PARTICULARLY FUR A RESEARCHER, THAT ONE OF THE SHIFTS AROUND THIS IS IT'S PERSON-DRIVEN. SO, IF YOU ARE A PAIN PATIENT, WE GO WHERE THE PERSON IS DRAWN WHICH IS A HUGE SHIFT THAT I DIDN'T CLARIFY. WHICH IS KIND OF CRAZY MAKING IF YOU ARE TRYING TO RESEARCH A SPECIFIC APPROACH BECAUSE REALLY WHAT WE'RE SEEING IS THAT APPROACH IS DRIVEN BY THE PERSON. THAT'S PART OF THE MODEL THAT IF IT'S AVAILABLE AND THERE'S EVIDENCE THAT IT COULD BE EFFECTIVE FOR THEM, THEY'RE GIVEN THE OPTION AND WHAT THEY ARE DRAWN TO IS WHERE THEY START. AND THAT IS A DIFFERENT SHIFT BUT WE FIND THAT OH, IF THEY GO WHERE THEY'RE DRAWN, NOW THEY STAY ENGAGE AND THEY'RE READY, IF THEY FOR EXAMPLE, IF THEY ALL WANT TO TAKE ON NUTRITION BUT THEY'RE INTERESTED IN ACCUPAUNCHTURE, GREAT, WHEN THEY GET PROGRESS THEY TAKE ON OTHER ASPECTS SO IT'S CHALLENGING AS A RESEARCHER BECAUSE IT DOESN'T FIT THE TYPICAL RANDOMIZED CONTROL TRIAL BECAUSE YOU HAVE A BLACK BOX. THAT IS INTEGRAL TO THIS APPROACH AND CREATES RESEARCH CHALLENGES I KNOW. >> THIS IS GREAT. THANK YOU. MAYBE ONE MORE QUESTION JUST TO START MAYBE CONVERSATIONS THAT WE CAN HAVE LATER MAYBE ON THE NETWORK TOMORROW. CAN YOU DISCUSS THE COST OF THE APPROACH TO THE SOCIETY AND TO THE HEALTH-CARE SYSTEM? >> YEAH, THAT'S A HUGE QUESTION. I DO THINK BEN, WHO IS RUNNING THE V.A. WORK AND HIS TEAM HE HAS EXCELLENT RESEARCHER TEAMS WORKING WITH HIM ARE VERY MUCH LOOKING AT THE COST AND THE IMPACT OF COST. SO THAT IS A -- I WILL JUST SAY TO END US, I KNOW THIS SESSION IS OVER THAT WHAT IS REALLY ENCOURAGING IS IT'S NOT -- IT DOES NOT APPEAR TO BE COST NEUTRAL BUT COST SAVINGS, NOT JUST IN PAIN BUT IN OTHER AREAS OF HEALTHCARE AS WELL WHICH MAKES SENSE. THESE ARE NOT HIGH COST INTERVENTIONS SO IT MAKES SENSE THAT, AND EVEN USING PEERS FOR EXAMPLE, TO DELIVER A LOT OF THESE APPROACHES, TO DELIVER THE CONVERSATIONS AND THE ENGAGEMENT RATHER THAN CLINICIANS AND YOU CAN SEE PRACTICALLY WHERE THAT WOULD BE SCALABLE AND COST EFFECTIVE AND SO NA IS WHAT WE ARE DISCOVERING AND THERE NEEDS TO BE A LOT MORE RESEARCH ON THAT AND THAT IS ON GOING AND IT'S WE WOULD BE A BIGGER UPHILL BATTLE IF IT WORKS MORE AND IT DOESN'T. >> THANK YOU FOR THIS VERY, VERY CONVERSATION AND FOR THE EXCELLENCE PRESENTATION AND THERE ARE SO MANY QUESTIONS AND AND THE QUESTIONS WE CAN'T POINT TO DURING THIS Q&A, WHAT ARE THE BIGGEST BARRIERS TO INCREASING IMPLEMENTED WHOLE POSITIVE APPROACH AND HOW CAN WE OVERCOME THOSE BARRIERS SO HOPEFULLY THE REST OF THESE TWO DAYS SYMPOSIUM WILL RESPONSE TO THESE QUESTIONS AND HOPEFULLY WE HAVE ANOTHER CONVERSATION ON THESE QUESTIONS THE NETWORK TOMORROW AND THANK YOU AGAIN. YOU GO AGAIN SO MUCH. >> WE ARE NOW MOVING TO THE SESSION AND I'M PLEASED TO INVITE MY COLLEAGUES Dr. ALEX TUTTLE WHO WILL WILL MODERATE THIS SESSION. HE IS THE PROGRAM DIRECTOR IN THE MECHANISTIC BRANCH AS THE NATIONAL CENTER FOR COMPLIMENTARY AND INGRAY TIVE HELP WHERE HE MANAGED THE MANUAL THERAPY AND BASIC PORTFOLIOS. Dr. TUTTLE OVERSEES SEVERAL PROBLEMS IN THE HELPING TO END ADDICTION LONG-TERM, HEAL INITIATIVE INCLUDING THE BIOMARKERS PROGRAM AND AS WELL AS (INAUDIBLE). Dr. TUSSLE OBTAINED HIS PH.D IN PSYCHOLOGY FROM THE UNIVERSITY OF MCGILL AND A SPECIALIST AS A NATIONAL INNS FOR NEUROLOGICAL DISORDERS. WITH THIS, Dr. TUSSLE, PLEASE CARRY AWAY. >> THANK YOU. I APPRECIATE THE INTRODUCTION AND GOOD AFTERNOON, EVERYONE. I AM DELIGHT TODAY MODERATE THE FIRST PANEL SESSION OF THIS YEAR'S SYMPOSIUM. WE'LL BEGIN WITH AN OVERVIEW OF THE COMPLEX OVERVIEW OF THE PAIN AND CO MORBID TEASE PRESENTED BY Dr. TRACY PEREZ KOEHLMOOS AS WELL AS SUBSTANCE USE DISORDERS FROM Dr. ILGEN AND Dr. PATRICK FINAN AND SAWSAN AS-SANIE WE WILL POSE YOUR QUESTIONS TO THE PANELISTS, PLEASE SUBMIT YOUR QUESTIONS USING THE Q&A BOX. IT IS NOW MY DISTINCT PLEASURE TO INTRODUCE Dr. KOEHLMOOS THE DIRECTOR OF HEALTH SERVICES RESEARCH AND DIRECTOR OF DOCTORAL PROGRAMS IN PUBLIC-HEALTH AT THE UNIVERSITY OF THE HEALTH SCIENCES. WHICH SHE LEADS THE DEVELOPMENT OF ROBUST HEALTH SERVICES, POLICY RESEARCH, AND GRADUATE PROGRAMS. WITH 200 PUBLICATIONS SHE'S A DISTINGUISHED HEALTH SYSTEMS AND POLICY EXPERT AND SHE'S THE NATIONAL SECRETARY OF GOLD STAR WIVES OF AMERICA AND AS THE DEPUTY CHAIR OF THE COCHRAN LIBRARY OVERSIGHT COMMITTEE. PRIOR TO JOINING USUHS IN 2015, SHE SERVED AS THE SPECIAL THE ASSISTANT TO THE ASSISTANT COMMAND ANT OF THE MARINE CORE. A FORMER ARMY AIR DEFENSE ARTILLERY OFFICER SHE'S THE WIDOW OF CORNUAL RANDEL KOEHLMOOS AND A MOTHER OF THREE MILITARY MEMBERS. THANK YOU FOR JOINING US TODAY. >> THANK YOU FOR THAT KIND INTRODUCTION, ALEX. SO WELCOME, EVERYBODY. I HAVE ABOUT 40 SLIDES AND 20 MINUTES SO I DO HOPE TO MOVE THROUGH THIS QUICKLY BECAUSE I'M A TEACHER IN MY DAY JOB, I'M GOING TO START MY TIMER SO THAT I CAN STAY ON TRACK AND I DO HOPE PEOPLE WILL ADD THEIR QUESTIONS TO THE END AND FOR EVERYONE WHO IS DIALED IN YOUR IN FOR A TREAT. IT'S RARE THAT ANYBODY GETS TO BE ON THE CALL WITH MORE THAN ONE TRACY AND WE JUST HEARD FROM MY COLLEAGUE TRACY GAUDET AND NOW YOU'VE GOT ME, WE'RE GOING TO TALK ABOUT THIS ISSUE OF PAIN AND COMPLEXITY AND CO-MORBIDITY THROUGH THE LENS OF THE U.S. MILITARY HEALTH SYSTEM. IT'S THE STAND AR DISCLAIMER, I AM A FEDERAL GOVERNMENT EMPLOYEE AND ANYTHING THAT I SAY DOES NOT REFLECT THE VIEWS OF ANY AGENCY. THAT WAS TO SHOW YOU WHERE WE'RE GOING. LET'S TALK ABOUT PAIN. I THINK THE AUDIENCE AND THE PARTICIPANTS IN THIS PANEL DON'T NEED ANY REMINDERS ABOUT WHAT PAIN IS OR HOW IT IMPACTS OUR ENVIRONMENT AND THERE'S ENVIRONMENTAL FEELINGS, BEHAVIORS ALL THAT TAKE PLACE AND I WILL PACT OUR EXPERIENCE OF PAIN. THERE'S STANDARD ONES THAT COME WITH CHRONIC PAIN WHEN WE'RE IN PAIN AND OUR FOODS ARE ALTERED AND WE CAN'T SLEEP AND WE MAY HAVE DYSFUNCTION WHILE WE TRY TO MANAGE THE THESE THINGS SO THEY TREMENDOUSLY REDUCE THE QUALITY OF LIFE FOR PATIENTS, FOR OUR FRIENDS, OUR FAMILIES, OUR LEVELS AND NEXT SLIDE, PLEASE. WE TALK A LOT IF WE'RE GOING TO TALK ABOUT WHOLE PERSONNEL HEALTH, HOW WE CAN ASSESS TREAT AND MANAGE PAIN AND CHRONIC PAIN PARTICULARLY IN A HOLISTIC PLANNER THAT BRINGS PEOPLE BACK TO BOTH FEELING BETTER AND BETTER FUNCTIONING. I DO TALK ABOUT RESEARCH AND WORK THAT WE'VE DONE AND YOU MIGHT THINK IT'S BEING ACTIVE DUTIES AND YOU WOULD BE INCORRECT ONLY ABOUT 18% OF OUR 9.6 MILLION FIN FISH ARY ARE ON ACTIVE DUTIES AND EVERYONE ELSE COMES TO US AS GOD MADE THEM. IT'S THE SPOUSES, THE CHILDREN AND 2 MILLION CHILDREN WHO ARE POPULATION OF THE CHILDREN IT'S OUR RETIREES AND THEY OFTEN STAY ON AND THEY ARE 9.6 MILLION BENEFICIARIES SPREAD OUT ACROSS THE COUNTRY. DOB A RETIREE IN OUR SYSTEM DOESN'T NECESSARILY MEAN THAT YOU ARE AGE 65. WE HAVE RETIREES WHO CAN BE AS YOUNG AS PAGE 38 WHO SERVED THEIR FULL 20 YEARS AND KEEP THIS MILITARY TRY-CARE BENEFIT INTO THEIR PERSONAL RETIREMENT IN ADDITION TO PERHAPS SEEKING CARE INSIDE THE VETERAN'S HEALTH ADMINISTRATION. AND THE SYSTEM ITSELF COST THE U.S. GOVERNMENT A $53 BILLION A YEAR WHICH IS A VERY SMALL 10% OF THE ENTIRE BUDGET WHEN WE TALK ABOUT HEALTH INSURANCE AND EVERYBODY ON THIS CALL HAS SOME FORM OF HEALTH INSURANCE AND THIS IS HEALTH INSURANCE WITH NO OR LOCO PAYMENTS NEW YORK CITY PREMIUMS AND IT'S AN INCLUSIVE WITH A TREMENDOUS BENEFITS SO THERE'S HOWEVER, IN ORDER TO HELP MEET THE SECURITY NEEDS OF THE U.S. ARMED FORCES, WE MAINTAIN AND OPERATE OUR GLOBALLY REPRESENT TEN AND GEOGRAPHICALLY DISBURSE THE HEALTH-CARE SYSTEM WITH MORE THAN 375 DIFFERENT CLINICS. MAJOR MEDICAL HOSPITALS ACROSS THE U.S. IN GUAM, JAPAN AND OTHER PLACES, WE SET UP DEPLOYED FACILITIES WHERE OUR ARMED FORCES MEMBERS AND SOLDIERS, SAILORS AND MARINES GO TO NATIONAL SECURITY OBJECTIVES FOR THE UNITED STATES SO WE CAN SET UP A HOSPITAL AND STATION AND DELIVER HEALTHCARE ON THE DROP OF A DIME WE JUST HEARD FROM THE OTHER TRACY WHO SPOKE ABOUT THE VETERAN'S HEALTH ADMINISTRATION. VETERANS HEALTH AND HEALTHCARE AND IT'S IMPORTANT TO KNOW THESE ARE TWO SEPARATE SYSTEMS WHEN WE TALK ABOUT THE V.A. WE'RE TALKING ABOUT INDIVIDUALS WITH PRIOR ACTIVE DUTY MILITARY SERVICE AND IT DOESN'T NECESSARILY INCLUDE THE ACTIVE DUTY SERVICE MEMBERS OR INCLUDE THE DEPENDENCE OF SPOUSES FOR THE CHILDREN AND IT CERTAINLY DOESN'T INCLUDE ALL OF THE PEOPLE WHO RETIRE OR LEAVE THE MILITARY. DON NECESSARILY QUALIFY FOR HEALTHCARE IN THE V.A. WE HAVE 9.6 MILLION BENEFICIARIES AND WE TREAT OUR PROVIDERS AND IT'S A DIFFERENT STRUCTURE AND THE IMPORTANT TAKEAWAY IS THAT THESE TWO ELECTRONIC HEALTH RECORDS DO NOT TALK TO EACH OTHER AND THEY'RE TWO SEPARATE SYSTEMS AND IT'S HELPFUL FOR PEOPLE TO REMEMBER THAT. WE'RE WORKING ON GETTING A SINGLE ELECTRONIC HEALTH RECORD SO IT'S NOT IN THE PROCESS OF HAPPENING NOW BUT IT'S MORE OF A LONG-TERM VISION. AND THE CURRENT 20 YEARS OR I GUESS WE JUST WRAPPED UP AND TRY ADDS AND OUR NEXT SLIDE PLEASE. THIS CONSIST OF TRAIN INJURIES POST TRAUMATIC STRESS DISORDER AND OFTEN FOR SOMETHING LESS AND WE LOOKED INSIDE. >> A CARE DOCTOR DEALING WITH THE PAIN ISSUES AND SO WE SAW DIFFERENT PROVIDERS. IT WAS DISJOINTED. SO, WE WENT OUT AND REALLY THE FIRST STEP WHEN YOU HAVE A PROBLEM IS IDENTIFYING THAT YOU HAVE A PROBLEM AND IT'S LIKE A 12-STEP PROBLEM. OVER A FIVE-YEAR PERIOD FROM 2010 TO 2015 COMING OFF THE HEIGHT OF THE THE SURGE IN AFGHANISTAN, WE IDENTIFIED 15,000PCT PATIENTS WHO SHOWED THE SYMPTOMS USING OUR MILITARY HEALTH SYSTEM REPOSITORY. THIS IS THE GROUP OF PATIENTS WE IDENTIFIED AND THIS IN DEED WAS THE LARGEST GROUP WITH THE POLY TRAUMA MEDICAL TRIAD AND THERE WERE VETERANS THAT ARE STUDIED IN SOME DETAIL AND ON THE SURVIVORS IS IT ON GOING NOW BUT OF COURSE THE FIRST STEP IS ALWAYS TRYING TO FIGURE OUT WHO DO YOU HAVE IN THIS POPULATION. WHERE ARE THEY? WHAT'S GOING ON WITH THEM? WHAT ARE THEY DOING? WHY DO THEY HAVE MUSS CUE TAL PAIN. ALL OF THAT WORK IS GOING ON NOW ACROSS DIFFERENT VENUES IN THE DEPARTMENT OF DEFENSE AND THE MILITARY HEALTH SYSTEMS. SO THE CORNER STONE OF THESE LAST 20 YEARS OF COMBAT IN AFGHANISTAN AND IRAQ. IT WOULD BE TRAUMATIC BRAIN INJURY, WHICH OF COURSE, WE OFTEN THINK OF IT AS CONCUSSION, CONTUSION, PENETRATING INJURIES AND IT'S DIS ACT AND DEATH IN ADULTS IN GENERAL AND YOU WILL SEE THAT DURING AFGHANISTAN, WE HAD A TREMENDOUSLY HIGHER RATE OF HEAD INJURIES THAN ANY OTHER TIME, HALF A MILLION TRAUMATIC BRAIN INJURIES DURING THE OEF, OPERATION ENDURING FREEDOM AND SO THE SHARE OF WHICH WERE MILD BUT NOT NEGLIGIBLE SO THIS WAS REALLY THE TAKE-HOME THING WE HAD TO DEAL WITH BOTH IN WAYS WHERE THE CONCLUSION WE KNOW FROM HIGH SCHOOL FOOTBALL OR SPORTS, BUT ALSO THE SQUEEZE, THE COMPRESSION INJURIES THAT CAUSED A TRAUMATIC BRAIN INJURY IN THE SENSE THAT THE SQUEEZING MIGHT SOMEHOW BE DIFFERENT OR MORE DAMAGING THAN OTHER TYPES OF CONCUSSIVE EVENTS. WE WENT OUT AND WE LOOKED BETWEEN 2016 AND 2019 AT WHERE ACTIVE NATIONAL GUARD YOU CAN SEE IN THE MOUNTAIN AND TEXAS AND WE LOOKED AT THE ESTABLISH OF ESTABLISHING WHERE WE MIGHT DEVELOP SERVICES BETWEEN THE DEPARTMENT OF DEFENSE AND THE V.A. AND IT MIGHT TREAT AND HELP THESE PATIENTS LIVE AND MANAGE THEIR CONDITIONS GOING FORWARD. AS THEY REINTEGRATE INTO POPULATION AND TRY TO ENJOY THE REST OF THEIR HAPPY LIVES THE OTHER THING THAT IS IMPORTANT ABOUT TRAUMATIC BRAIN INJURY IS MILD AND MODERATE IT HAS A LONG-TERM IMPACT ON A PATIENT AND THERE ARE MORE EXPENSIVE TO TREAT SO FROM A HEALTH SYSTEMS PERSPECTIVE, PEOPLE TALK ABOUT THE MILITARY HEALTH SYSTEM OR THE V.A. HEALTH SYSTEM BECAUSE THERE'S NO PREMIUM DEDUCTIBLE FOR ACTIVE DUTY INDIVIDUALS, NO CO PAYMENT, THERE'S A SENSE OF WE DON'T THINK ABOUT MONEY BUT WE DO BECAUSE EVERY PENNY AT LEAST IN THE DOD THAT GOES TO HEALTHCARE, IS ONE THAT US DOESN'T GO FOR AIRPLANES, TANKS, WEAPONS, SHIPS AT SEA DURING POWER PROJECTION FOR THE UNITED STATES AND SO WE ACTUALLY CARE A GREAT DEAL ABOUT COST. AS WE MOVE FROM MILD TO MODERATE AND SEVERE WE SEE HOW EXPENSIVE THIS IS FOR THE PATIENT POPULATION AND THE HEALTH SYSTEM IN HEALTH SO NEXT SLIDE, PLEASE. SO IDENTIFYING WE ARE HAVING A MONSTER PROBLEM WITH THE CROP I CAN ISSUES OF T BYE THE DEPARTMENT OF STINTS STOOD UP THE NATIONAL INTREPID CENTER WHERE WORKING ON THE CAMPUS ACROSS THE STREET FROM THE NIH SO MAYBE NEXT YEAR, WHEN WE'RE ALL TOGETHER AT THE NIH IT'S SO NICE AND WE'LL BE RIGHT ACROSS FROM THE STOOD UP IN 2010 AND THEN THEIR SATELLITE SPIRIT CENTERS ACROSS THE NATION THERE'S 13 PARTNER SITES AND RATHER THAN HAVING THIS PRAG INVESTMENTED CARE WHERE WE TREAT T BYE OR HEADACHES IN ONE PLACE, DIFFERENT PROVIDERS AND MANAGING THOSE SLEEP DISTURBANCES BALANCE DISTURBANCE AND EYE DISTURBANCES AND ALL IN DIFFERENT PLACES, THESE WERE PRACTICE UNITS AND MODELS THAT HAVE BEEN STOOD UP AND REPEATEDLY SORT OF TEST SOD SEE HOW THEY'RE WORKING IN THROUGH THEIR INTENSIVE OUT PATIENT AND THE THEY HAVE NICO HAS A INTENSIVE MONTH-LONG PROGRAM AS WELL WHERE ALL OF THE SERVICES ARE COAL LATED AND ALL THE PATIENTS SCREENING RESULTS THAT ARE SHARED ACROSS THE PROVIDERS AS THAT INDIVIDUAL MOVES THROUGH THE PRACTICE UNITS AND RECEIVES REALLY THE TAILORED CARE THAT THEY NEED. SOME OF WHICH IS STANDARD PRACTICE OF CARE AND HEARING AIDS VISION AND EYEGLASSES, PAIN AND PAIN MANAGEMENT BUT IT'S ALSO THINGS LIKE ENTA RATE IS TIVE MEDICINE WHICH I'M GOING TO TALK ABOUT THE NEXT FEW MINUTES BEFORE MY TALK COMES TO A RAPID CLOSE. LET'S TALK ABOUT INGRAY TIVE MEDICINE AND IN THE DEPARTMENT OF DEFENSE WE ARE FANS OF ENTA GREAT TIVE MEDICINE OUR PROVIDERS, PATIENTS AND FAMILY MEMBERS AND WE'RE MONSTER FANS OF MEDICINE AND WE OFTEN TO OUR DISMAY, GET UP SET WITH THE IDEA THAT ACTIVE DUTY SERVICE MEMBERS WOULD PREFER TO HANG UPSIDE DOWN BY BOOTS OR WEAR A HAT WITH ELECTRODES AND WATCH A CERTAIN TYPE OF PROGRAMMING OR DRINK A POSITION IN THEIR GLASS AND TAKE AN FDA APPROVED PILL TO HELP MANAGE THEIR PAIN OR CONDITION. WHEN WE TALK ABOUT IM IT'S THROUGH THE LENS OF ACTUALLY TRYING TO MEET THE NEEDS OF A POPULATION THAT IS DEMANDING THINGS OTHER THAN OVER THE COUNTER MEDICATIONS, OR PRESCRIPTION MEDICATIONS AND THERE'S A REAL BIAS TOWARDS NOT BEING MEDICATED ON ACTIVE DUTY EVEN IF IT'S REALLY SOMETHING THAT WE MAKE INDIVIDUALS FEEL BETTER AND BE MORE WHOLE AND HEALED. SO YOU CAN UNDERSTAND WHERE WORE COMING FROM AND AGAIN, IT'S REALLY, IT'S THIS WHOLE PERSON APPROACH TO ACHIEVE OPTIMAL, MENTAL, PHYSICAL, AND ENVIRONMENTAL HEALTH AND SOME OF THESE ARE QUITE CONVENTIONAL AND OTHERS ARE LESS CONVENTIONAL AND OF COURSE THE GOAL IS WHERE THINGS ARE NOT CONVENTIONAL, TO DEVELOP THE EVIDENCE ABOUT WHETHER THEY SHOULD BE INCLUDED IN PRACTICE OR NOT AND ALL OF THIS CENTER WE COME TO THIS EXPERIENCE WITH THE SAME DESIRE, AT LEAST THE SCIENTISTS DO, NEXT SLIDE, PLEASE. SO THERE'S A NUMBER OF DIFFERENT THINGS THAT CAN TOWARDS HEALTH AND MUCH OF THIS IS EVIDENCE-BASED. THINGS LIKE YOGA OR MEDICATION, RIGHT, FOR PAIN MANAGEMENT AND CHIROPRACTORS, COGNITIVE BEHAVIORAL THERAPY IS A NORM BUT IT'S ENTA GREAT TIVE MEDICINE AND WE'RE MONSTER FANS OF AFTERNOON YOU PUNCTURE IN THE MILITARY HEALTH SYSTEMS SO THESE ARE JUST ONCE THAT WE USE AND SERVICE MEMBERS USE MILITARY MEMBERS AND FAMILIES USE NON CONVENTIONAL THERAPIES AT A MUCH HIGHER RATE THAN CIVILIANS EARLY SURVEYS OF SERVICE MEMBERS SHOW THEY WANT MORE OF THIS SO IT'S OUR CENTER ALIGN WITH THE INTEREST OF GROUPS AT THE NIH AND NEXT SLIDE, PLEASE. I'VE GOT ABOUT THROW AND A HALF MINUTES LEFT AND THERE'S SOME THAT ARE EFFECTIVE CLEANING THE POLY TRAUMA AND ACUPUNCTURE AND I HAVE SLIDES I HOPE I CAN GET TO AND YOGA NEXT SLIDE. LET'S KEEP GOING. AFTERNOON YOU PUNCTURE WE WENT OUT AND WE LOOKED AT WHAT WAS GOING ON IN THE MILITARY HEALTH SYSTEM AND YOU WILL SEE A LOT OF SERVICE MEMBERS WALKING AROUND WITH THE RANK YOU PUNCTURE TREATMENT AND WE KNOW THAT FOR PAIN OPINIONS AND MORE THAN 83 MILITARY TREATMENT FACILITIES ACROSS THE COUNTRY, OFTEN IS THAT BUT WE ALSO TEACH OUR PROVIDERS A DIFFERENT SCHOOLS HOW TO DO ORAL ACU PUNK TIER SO THEY CAN BRING IT TO THE SHIFT. WHEN WE LOOKED AT THE DATA ON RANK YOU PURETURE USE USING THE MILITARY DATA REPOSITORY SO THIS ISN'T SELF-REPORTED ACUPUNCTURE USE THIS IS THE LOOKING AT THE HEALTH RECORDS OF OUR 9.6 MILLION BENEFICIARY AND IN 2014, WE HAD 15,000 PATIENTS AND THE MAJORITY WERE CAUCASIAN AND MEN AND THE MAJORITY WERE IN THE ARMY AND NOT A SURPRISE GIVING THE DEMOGRAPHIC BREAKDOWN AND OF THE MILITARY THE SAME WITH BLACK RACE AND THERE IS OVER REPRESENT IN THE MILITARY HEALTH SYSTEM SO FOR US THIS IS ACTUALLY A VERY THIS IS A VERY EQUITABLE RACE WISE DISTRIBUTION OF ACUPUNC ACUPUNCTURE.MILITARY HEALTH SYSTEM. A LITTLE BIT THROUGH NERVES AND SENSES AND WE PUBLISHED A PAPER LOOKING AT THE USE OF ACUPUNCTURE AND I DON'T THINK THIS RESULTS MADE IT IN HERE BUT THAT PAPER IS OUT AND AVAILABLE ON THE WESTBOUND YOU CAN FIND IT NEXT SLIDE, PLEASE. WE HAVE FIFTH DEMAND FROM OUR PROVIDERS TO BE TRAINED IN THIS SER ADVERTISE AND FROM OUR PATIENTS, ESPECIALLY OUR ACTIVE DUTY SERVICE MEMBERS FANS AND NEXT SLIDE. PAIN AS ALL OF YOU KNOW IS MULTIFACETED AND COMPLICATED AND WE STRUGGLE WITH THE POLY TRAUMA CLINICAL TRIAD AND TRYING TO FIGURE OUT HOW TO HELP BRING ACTIVE DUTY SERVICE MEMBERS BACK TO FULL HEALTH OR ENOUGH HEALTH AND WELL BEING THAT THEY CAN PERFORM THEIR SCROLL HAVE A HIGH-QUALITY OF LIFE WHETHER THEY'RE IN THE FOR THE FUTURE AGAIN WE HAVE THE THE NEXT SERIES OF SPEAKERS ARE COMING AFTER ME AND I'LL BE FOLLOWED BY Dr. SAWSAN AS-SANIE AND SO I THINK THE OTHER SPEAKERS WILL BE MORE FOCUSED ON INDIVIDUAL AREAS OF PAIN SO SO WE HAVE THESE SLIDES ANY QUESTIONS, COMMENTS, FEEDBACK YOU ARE WELCOME TO SHARE THOSE WITH ME AND THANK YOU ALL FOR GOING NEXT. >> THANK YOU SO MUCH. IT WAS SUCH -- THANK YOU FOR A LOVELY INTRODUCTION AS WELL AS AN EXCELLENT LECTURE TO FOLLOW SO I HAVE BIG SHOES TO FEEL. I WOULD LIKE TO THINK THAT PAIN CONSORTIUM ORGANIZERS TO SHARE THE WORK ON REFRAMING ENDOMETRIOSIS. NEXT SLIDE. SO THE OBJECTIVE OF MY TALK TODAY ARE TO DEFINE ENDOMETRIOSIS AND REVIEW IT'S MOST COMMON SYMPTOMS AND I'M GOING TO PRESENT SOME EVIDENCE THAT WOMEN ARE PATIENTS WITH ENDOMETRIOSIS SHARE CLINICAL AND PHYSIOLOGICAL CHARACTERISTICS TO CHRONIC OVERLAPPING PAIN CONDITIONS AND THEN REVIEW THE CLINICAL AS WELL AS THE RESEARCH IMPLICATIONS OF PAIN IN THE EVALUATION AND TREATMENT OF PATIENTS WITH ENDOMETRIOSIS OR PELVIC PAIN. DROUIN-ULYSSE DROUIN-ULYSSE IS A CONTINUE DEFINED BY THE PRESENCE OF GLANDS AND STROM A OUTSIDE OF THE UTERUS. ON THE LEFT SIDE OF THE SCREEN IS AN EXAMPLE OF ENDOMETRIOSIS WITH A GLANCE IN STROMA AND A TYPICAL SURGICAL IMAGE THAT WE WOULD SEE AT THE TIME OF LAPAROSCOPY FOR A PATIENT WITH ENDOMETRIOSIS. SO ENDOMETRIOSIS EFFECTS 10% OF REPRODUCTIVE AGE WOMEN. I WANT TO CLARIFY THAT ENDOMETRIOSIS DOES EFFECT TRANS AND BINARY PATIENTS AND I'LL HOPE THAT EVERYONE UNDERSTANDS THAT THIS COVERS ALL OF THOSE PATIENTS. SO THIS REPRESENTS OVER 200 MILLION PEOPLE GLOBALLY MAKING IT MORE COMMON THAN ASTHMA AND DIABETES. THE PREVALENCE OF ENDOMETRIOSIS IS MUCH HIGHER IN SPECIFIC POPULATIONS SO IT OCCURS IN ABOUT 30% OF PERSONS WITH SUB FERTILITY AND 60% TO 80% OF ADULTS WITH CHRONIC PELVIC BAIN AND 50% OF ADOLESCENTS OF CHRONIC PELVIC PAIN. THE MOST COMMON PRESENTING SYMPTOM OF ENDOMETRIOSIS IS PELVIC PAIN AND THIS INCLUDES DIS MEN ARIA DEFINED AS PAINFUL PERIODS, NON MENSTRUAL PELVIC PAIN AS WELL AS PAIN WITH SEXUAL INTERNET ARE COURSE. HOWEVER, PATIENTS ARE FREQUENTLY REPORTING OTHER SYMPTOMS WHICH ARE LISTED HERE. ANY COMBINATION OF SYMPTOMS CAN OCCUR, WHICH IS SHOWN IN THE DIAGRAM AND IT'S ALSO IMPORTANT TO NOTE THAT SOME PATIENTS HAVE LITTLE TO NO SYMPTOMS AT ALL FOR HAVING SIGNIFICANT DISEASE. MUCH IS KNOWN ABOUT THE PATHO PHYSIOLOGY OF ENDOMETRIOSIS AS IT RELATES TO THE INFLAMMATORY AND THE MECHANISMS THAT INITIATE AND SUSTAIN THE PROLIFERATION OF THESE ENDOMETRIOSIS. REN TREE GRADE MENSTRUATION IS THE MOST COMMON BUT NOT THE ONLY INITIATING FACTOR AND ALTERATIONS IN CELL ADHESION, LOCAL PELVIC AND NERVE FIBER FILTRATION AS WELL AS VASCULARIZATION ARE NECESSARY FOR THE ESTABLISHMENT OF THE LESIONS AND WE KNOW THAT IT'S NECESSARY TO STIM YOU LATE THIS PROCESS AND THE SUPPRESSION OF ESTROGEN IS IN SUPPRESSION AND REGRESSION OF THESE IMPLANTS. SO AS I PREVIOUSLY DESCRIBED, THE MOST PROMINENT SYMPTOM IS PELVIC PAIN AND THE TRADITIONAL AND MOST WIDELY PREVIOUS HEALTH VIEW IS ENDOMETRIOSIS IS A PAIN CONDITION THAT OCCURS DUE TO DIRECT ACTIVATION OF LESIONS. THE OVERWHELMING MAJORITY OF RESEARCH FUND TO GO DATE HAS FOCUSED ON UNDERSTANDING THE BIOLOGY OF ENDOMETRIOSIS LESIONS AND CURRENTLY THE ONLY FDA APPROVED TREATMENT ARE HOR MONDAYAL MEDICATIONS THAT SUPPRESSION PRODUCTION AND SUPPRESSION THE LESIONS AS WELL AS SURGERY OR DESTROYING LESIONS. IS IT THAT SIMPLE? AS MOST OF US WOULD UNDERSTAND, PARTICULARLY IN LIGHT OF THE PREVIOUS LECTURES, IT REALLY CANNOT BE THAT SIMPLE. WHILE IT'S CLEAR THEY'RE IMPORTANT THE RELATIONSHIP BETWEEN DROUIN-ULYSSE DROUIN-UENDOMETRIOSIS IS NOT EXD SO THERE'S MINIMAL RELATIONSHIP BETWEEN THE SEVERITY OF ENDOMETRIOSIS AND IT THIS IS SIM PAR TO PAIN CONDITIONS AND DOCUMENTED THAT THERE ARE PATIENTS WITH VERY ADVANCE DISEASE WHO HAVE LITTLE OR NO PAIN AND THAT ARE PATIENTS WITH ONE OR TWO VERY SMALL DEPOSITS THAT HAVE DEBILITATING LIFE-ALTERING PAIN. SECOND, TREATMENTS AIMED AT THE LESIONS DO NOT CONSIST ENDLY A MILLER' EIGHT SYMPTOMS SO PAIN IS IN 25% OF PATIENTS WHO UNDERGO MEDICAL AND SURGICAL THERAPY SO THEY'RE UNRESPONSIVE TO THAT AND PAIN RECURSE IN 50% OF PATIENTS FOLLOWING INCISION. THE PAIN COMES BACK AND IT OCCURS UP TO 10 TO 25% OF PATIENTS WHO UNDERGO HYSTERECTOMY AND 450% OF THEM THERE'S NO EVIDENCE OF RECURRENT ENDOMETRIOSIS LESIONS SO WE NEED TO REMEMBER THERE'S NO CHRONIC PAIN CONDITION THAT IS EXPLAINED BY PERIPHERAL PATHOLOGY BECAUSE THE CENTRAL NERVOUS SYSTEM HAS A POWERFUL ABILITY TO AMPLIFIED AS WELL AS DAMPEN SIGNALS. SO AS SUCH THE MODERN UNDERSTANDING OF PAIN IS THAT PAIN IS AN OUTPUT OF THE BRAIN THAT IS A BALANCE BETWEEN THE PERIPHERAL INPUT AND THE CENTRAL NERVOUS SYSTEM VOLUME CONTROL. SO PAIN IS DEFINED AS ANY NERVE DYSFUNCTION THAT PLAYS A ROLE IN MAINTAINING PAIN AND CAN LEAD TO CRON INPAIN INDEPENDENT THE SIGNALS. NO SIS ACCEPTIVE CRON EASTBOUNDW BACK PAIN AND -- AND THESE NO SIM PLASTIC PAIN ARE BY WIDESPREAD PAIN AND THESE PATIENTS HAVE A PAIR LIFETIME HISTORY -- PAIN IS ASKER BATED BY STRESSORS. AND THEN NOW NEXT SLIDE. SO, IT'S VERY IMPORTANT TO KNOW THESE CONDITIONS ARE NOT JUST PAIN DISORDERS BUT THESE ARE ALSO CHARACTERIZED BY GREATER SENSITIVITY TO INTERNAL SENSATIONS AS WELL AS GREATER SENSITIVITY TO SOUND AND LIGHT AND THESE PATIENTS ALSO EXPERIENCE CHRONIC FATIGUE, POOR OR NON RESTORATIVE SLEEP, MEMORY DIFFICULTIES AS WELL AS HIGHER PREVALENCE SUCH AS ANXIETY ASK DEPRESSION. SO THESE NOCIPLASTIC PAIN CO OCCUR AND THE COEXISTING PAIN CONDITIONS HAS BEEN RECOGNIZED BY THE NIH PAIN COR SO MANYION O ONE THANK THAT IS CLEAR IS THE PAIN CONDITIONS CO AND YOU ARE THIS IS A STUDY PUBLISHED BY Dr. WILLIAMS WHO IS GOING TO BE SPEAKING TOMORROW, AND USING A LIST OF CODES AND THEY DEMONSTRATED THAT ALL OF THESE CHRONIC OVERLAPPING PAIN CONDITIONS ARE ASSOCIATED WITH HAVING AN INCREASE ODDS OF HAVING AT LEAST ONE OTHER CHRONIC OVERLAPPING PAIN CONDITION SO THE STRONGEST ASSOCIATIONS HERE ARE SHOWN IN RED WHICH HAVE GREATER THAN FIVE AND THOSE THAT ARE MODERATE AND ODDS RATIO OF THROW TO FIVE AND MILD ONE TO THREE AND SO WHAT YOU CAN SEE HERE, FOR EXAMPLE, IS THAT PATIENTS WITH DEGREE TREMENDOMETRIOSISHAVE A 16 TIMES AND FIVE TIMES THE ODDS OF HAVING IRB AND FOUR TIMES THE ODDS OF HAVING FIBER MYALGIA. SO WHAT DO WE KNOW ABOUT ENDOMETRIOSIS SO I WAS ASKED TO TALK ABOUT THE RESEARCH THAT WE'VE BEEN DOING HERE AT THE UNIVERSITY OF MICHIGAN ON THIS TOPIC. AND WHAT OUR GROUP IS STUDIED THIS QUESTION BY COMPARING WOMEN OR PATIENTS WITH CHRONIC PELVIC PAIN INCLUDING THOSE WITH AND WITHOUT ENDOMETRIOSIS AND WE'VE COMPARED THEM TO PAIN-FREE HEALTHY CONTROLS AND WE FOUND THROW MAIN FINDINGS. FIRST, SO, NEXT, INCREASE SENSITIVITY TO THESE PATIENTS WITH CHRONIC PELVIC PAIN HAVE INCREASED SENSITIVITY TO PAIN AND SENSORY STIMULI AND THIS IS FOUND IN THE PEL VISION AS WELL AS A REGION DISTANT FROM THE SITE OF CLINICAL PAIN. CHANGES IN BRAIN STRUCTURE SIMILAR TO PAIN CONDITIONS AND WOMEN WITH CHRONIC PELVIC PAIN DEMONSTRATE VOLUME IN PAY REGULATORY REGIONS SUCH AS THE THALAMUS, AND NEXT. CHANGES IN BRAIN FUNCTION WITH INCREASE LEVELS OF NEURO TRANSMITTERS IN THE INSUL A AS WELL AS INCREASE DETECTIVE TEE BETWEEN PAIN REGULATORY REGIONS SAYS THE PRE FRONTAL CORTEX. SO THIS SUGGESTS THAT ONE POSSIBLE REASON THAT WOMEN WITH PAIN FREE ENDOMETRIOSIS EXPERIENCE LITTLE TO NO PAIN IS THEY MIGHT HAVE SOME ADAPTIVE BRAIN CHANGES THAT OFFSET OR DAMPEN THE INPUT. SO, IT'S WELL ESTABLISHED THAT ENDOMETRIOSIS IS AN ESTROGEN DISEASE THAT IS CHARACTERIZED BY PELVIC INFLAMMATION AS WELL AS SYSTEMIC INFLAMMATION SO THIS RAISES AN IMPORTANT QUESTION OF WHETHER THERE'S A LINK BETWEEN SYSTEMIC INFLAMMATION AND NO SIS PLASTIC PAIN SO THIS IS A COURTESY OF ONE OF MY COLLEAGUES AND COLLABORATORS AT THE UNIVERSITY OF MICHIGAN AND ILLUSTRATES -- SO THESE CELLS ARE KNOWN TO MODULATE COMMUNICATION BETWEEN NERVE FIBERS WHICH ARE STAINED RED HERE AND THESE CELLS ARE KNOWN TO EXPRESS RECEPTORS SO STIMULATION OF THESE RECEPTOR HAS BEEN SHOWN TO INDUCE RELEASE OF PRO INFLAMMATORY CYTOKINES IN THE SPINAL CORD. AND THIS IS THOUGHT TO BE ONE CONTRIBUTING MECHANISM FOR NOCIPLASTIC PAIN CHARACTERIZED BY THESE SYMPTOMS HERE. SO LYPO POLICY AK OWE RIGHT IS A WELL-KNOWN AGO A NICE AND USED TO STUDY THE RELATIONSHIP BETWEEN RECEPTOR STIMULATION MARKERS FOR CENTRAL SENSATION. SO, MEMBERS OF THE NIH FUNDED NETWORK HAVE INVESTIGATED THIS RELATIONSHIP IN FEMALE PATIENTS, AND IN THIS PAPER THAT WAS PUBLISHED IN 2015 THEY EXAM THE RELATIONSHIP BETWEEN THE SITE OWE KEEN RESPONSE TO LPS STIMULATION OF ISOLATED MONO NUCLEAR CELLS AND THEY FOUND THAT FOR EVERY ONE STANDARD DEVIATION IN INCREASE IN THE RECEPTOR FOR IN FLAM TORI RESPONSE THERE WAS A 60% INCREASE IN THE LIKELIHOOD OF REPORTING WIDESPREAD PAIN. AS SHOWN WHERE DARK COLOR REPRESENT A PREPORTION THOSE PATIENTS WITH THE LOW TAYLOR OF FOUR RESPONSE GENERALLY HAD LOCALIZED PAIN. HOWEVER, THIS IS IN STARK CON TCONTRAST WITH THOSE THAT ARE CHARACTERIZED BY HAVING WIDESPREAD PAIN WHICH IS NO SEE PLASTIC PAIN. SO THEY DETERMINE WHETHER A SIMILAR RELATIONSHIP OCCURS IN WOMEN WITH CHRONIC PELVIC PAIN AND IT'S A PROSPECTIVE OBSERVATIONAL COHORT STUDY INVESTIGATING WHETHER PER I HAVE PRO DICTIONARIORS ARE PRESENT FOR PAIN. SO, IN THOSE PRELIMINARY DATA, WE EXAM 17 WOMEN AWAITING HISS TERRECTOMY AND NOT USING HORMONAL THERAPY AND THEY WERE STIMULATED WITH LPS FOR 24 HOURS AND WE SHOW A CORRELATION PLOT AND WHAT WE FOUND WAS IS THAT MID ONE ALPHA, ONE OF THE CYTOKINES MEASURED WAS ASSOCIATED WITH ALL SUB TYPES OF PELVIC PAIN SYMPTOMS, AND NEXT TO VALIDATE THESE FINDINGS IN A SECOND COHORT THERE WAS A SIMILAR ANALYSIS IN 15 PRE MENOPAUSAL WITH ENDOMETRIOSIS AS WELL AS YOU'RE LOGIC PAIN OF THE MAP NETWORK AND CONFIRMED THE SAME RELATIONSHIP. SO WE THEN EXAMINED THE RELATIONSHIP BETWEEN THE PROVOKED INFLAMMATION AS WELL AS FUNCTIONAL BRAIN IMAGING AND WE CONDUCTED A SEED REGION TO HOLD BRAIN ANALYSIS IN THESE SAME PATIENTS TO IDENTIFY WHETHER THEY WERE BRAIN REGIONS THAT WERE MODULATED BY SYSTEMIC INFLAMMATION AND THE SEED WAS PLACED IN THE PELVIC TRUNK IN THE S1 CORTEX WHICH IS SHOWN IN PANEL A. AND WHAT WE FOUND WAS THAT AS MID 1 ALPHA LEVELS SHOWN IN PANEL C, THE CORRELATION BETWEEN PELVIC S1 AND IT STRONGLY SUGGESTS THAT THE RELATIONSHIP BETWEEN SYSTEMIC INFLAMMATION IN THE CENTRAL NERVOUS SYSTEM AND THE PRO SIGHSLY EXPECTED BRAIN REGION IS A PELVIC PAIN SAMPLE. WE FEEL THIS IS UNLIKELY TO BE FINDING SINCE THE CORTEX WAS IMPLICATED AND SYSTEMIC INFLAMMATION AND BRAIN CONNECTIVE TIE AND THAT WAS PUBLISHED IN 2018. SO WHY DOES THIS MATTER? I AM A CLINICIAN AND I SPEND MY TIME ACTUALLY SEEING PATIENT IN CLINIC SO HOW DO WE APPLY THIS TO CLINICAL CARE AS WELL AS RESEARCH? SO FIRST AND FOREMOST, IDENTIFYING RELEVANT BIOLOGICAL MARK OFFICERS IMPORTANT FOR DECISION MAKING AND WE NEED TO MAKE OUR DEXES BASED ON THE UNDERLINE PAIN MECHANISM. SO WHILE ENDOMETRIOSIS IS A PATHWAY THERE ARE MANY OTHER PATHWAYS INCLUDING SENSE TAIZATION. AND AS WELL AS ALL OF THESE THINGS CAN BE MODIFIED BY INFLUENCED BY GENETIC VARIABILITY AS WELL AS TRAUMA. WE ALSO NEED TO RECOGNIZE THAT THESE PATIENTS ARE HETEROGENEOUS AND THEY CAN BE DIFFERENT FROM EACH SO MIGHT HAVE NO SUN ACCEPTIVE PAIN LIKE ON THE FAR-LEFT AS WELL AS SOME PATIENTS YOU HAVE NOCIPLASTIC PAIN IN THE LEFT AND THE MIDDLE WHO HAVE MIXED PAIN CONDITION. >> WE NODE TO MOVE ON TO THE NEXT SPEAKER, PLEASE. GIVE A CONCLUDING SENTENCE, THANK YOU. >> SO, I APOLOGIZE. IN CONCLUSION, I THINK THAT IT'S JUST CRITICAL TO UNDERSTAND THAT REALLY ENDOMETRIOSIS WE NEED TO MOVE BEYOND THE LESION AND THINK OF IT AS A SYSTEMIC DISEASE. THANK YOU. >> THANK YOU. WE HAVE Dr. FINAN NEXT. >> >> FANTASTIC. THANK YOU SO MUCH FOR THAT TALK. THAT WAS REALLY ENLIGHTENING. AND THANK YOU ALL FOR ATTENDING OUR SESSION TODAY. MY NAME IS PATRICK FINAN FROM THE DEPARTMENT OF PSYCHIATRY AND BEHAVIORAL SCIENCES AT JOHNS HOPKINS SCHOOL OF MEDICINE. FIRST OF ALL, THANK YOU TO THE PAIN CONSORTIUM FOR THE INVITATION TO SPEAK HERE TODAY. IT'S AN HONOR TO BE HERE. TODAY I'M GOING TO TALK ABOUT THE ASSOCIATION OF SLEEP AND PAIN BUT IN THE SPIRIT OF TACKLING THIS ISSUE FROM A WHOLE PERSON PERSPECTIVE, I'M GOING TO FOCUS THE DISCUSSION BY CONTEXTUALIZING THAT RELATIONSHIP IN TERMS OF EFFECTIVE FUNCTION WHICH I THINK IS A CRITICAL FOCAL POINT IN UNDERSTANDING HOW THESE TWO MAJOR BIO PSYCHOSOCIAL SYSTEM INTERACT. NEXT SLIDE, PLEASE. SO, I SHOULD NOTE I'M ON THE SCIENTIFIC ADVISORY BOARD ON A COMPANY NOT RELATED WHAT I'M GOING TO TALK TO YOU ABOUT TODAY. SO, THE EFFECTS OF SLEEP ON PAIN ARE NOW QUITE WELL ESTABLISHED. WE KNOW FOR EXAMPLE THAT UPWARDS OF 50% OR MORE OF PATIENTS WITH CHRONIC PAIN, REPORT SLEEP DISTURBANCES WHICH IS INSOMNIA OR DIFFICULTY FALLING OR STAYING ALI WITH ACCOMPANIES DAYTIME IMPAIRMENTS. MANY PATIENTS WHO MAY NOT MEET CRYIA AND AND STUDIES HAVE INCORPORATED PROSPECT OF DESIGNS A TREND IN THE DATA IS EMERGED AND SUPPORTING THE HYPOTHESIS THAT SLEEP PROBLEMS MAY CAUSE INCREASE PAIN PER EXPERIENCE AND THE INCIDENTS OF CHRONIC PAIN AND THEY SUPPORT INCREASES PAIN SENSE ACTIVITY AND SO HOW DOES THIS HAPPEN? THERE ARE OF COURSE A NUMBER OF PLAUSIBLE MECHANISM TO CONSIDER LIKE INFLAMMATION, OR NEURO ENDOCRINE FUNCTION, DIRECTION BUT THE WORK HAS CENTERED PRINCIPALLY AROUND EFFECTIVE FUNCTION AND POSITIVE EFFECT AND THE SO-CALLED REWARDS SYSTEM. WE HAVE TO EFFECT MODELS OF EITHER SLEEP OR PAIN FOCUSED ON NEGATIVE AFFECT AND AND AS THIS STARTED TO CHANGE WHICH OCCURRED WITH INFLUENTIAL NUDGING BY MY LATE, GREAT, ALEX SALTRA AND MARY DAVIS AMONG OTHERS IN THE PAIN SPACE AND IN POSITIVE AND TO SLEEP LOSS THAN NEGATIVE EMOTIONAL RESPONSES. THIS WAS WORK I'VE BEEN DOING FROM THE EARLY SLEEP DISRUPTION EXPERIMENTS SO WE SET OUT TO BUILD A MODEL THAT INCORPORATED EFFECT THERE ARE COMPONENTS OF COGNITIVE THERAPIES CRUX LIKE POSITIVE REAPPRAISAL, PRO SOCIAL COPING, STATE MINDFULNESS AND OTHERS THAT MAY BE THERAPEUTICALLY HARNESSES TO ENGENDER A STATE OF RESILIENT PAIN SELF-MANAGEMENT AND THAT THEY MAY DO SO BY OPTIMIZING FOR ENHANCED POSITIVE EFFECT AND OTHER POSITIVE STATES IN AN EFFORT TO DIMINISH THE MAGNITUDE OF COUPLING BETWEEN PAIN AND EFFECT NIH AFFECT OR NEGATIVE AFFECTIVE OF REACTIVITY TO PAIN. SO OUR SLEEP WORK IS REALLY AN N EXTENSION OF THIS MODEL AND WE'RE INTERESTED IN UNDERSTANDING TO WHAT EXTENT DO SLEEP PROBLEMS OPERATE UPSTREAM OF THESE PROCESSES. AND CAN WE MODIFIED SLEEP THERAPEUTICALLY OR EXPERIMENTALLY IN A WAY THAT INVESTIGSTRENGTHENS THESE EFFEC. WE FOUND DIRECT EXPERIMENTAL SUPPORT FOR THE OBSERVATION FOR PALMER ANDAL FAN OWE LITERATURE REVIEW THAT SLEEP LOSS, UNDER CERTAIN CONDITIONS, TARGETS POSITIVE EFFECT OVER NEGATIVE AND IN THIS STUDY 45 HEALTHY PARTICIPANTS WERE ENROLLED WITHIN SUBJECT AND COUNTERBALANCED EXPERIMENT WHERE EVERYONE RECEIVED ONE NIGHT OF NORMAL SLEEP AND ONE NIGHT OF SLEEP DISRUPTION FORCED NOCTURNAL AWAKENINGS. SO, JUST REMEMBER THAT GENERAL EXPERIMENTAL PARADIGM THAT I'M GOING TO COME BACK TO SEVERAL TIMES THROUGHOUT THIS TALK. WE ADMINISTERED A NUMBER OF MEASURES IN TASKS RELEVANT HERE. IN THIS CASE WE SAW A SIGNIFICANT REDUCTION IN POSITIVE EFFECT FOLLOWING FORCED AWAKENINGS BUT NO INCREASE IN NEGATIVE EFFECT. AND IMPORTANTLY, THIS APPEARED TO GENERALIZE TO BOTH HIGH AK TAIZATION POSITIVE EMOTIONAL STATES LIKE JOVIALITY AND LOW STATES LIKE SERENITY. NOW ASSISTANT PROFESSOR AT ARIZONA STATE UNIVERSITY EXTENDED THESE EXPERIMENTAL FINDINGS INTO THE CLINICAL REAL. THIS WAS ANALYSIS OF TWO WEEKS IN MORNING AND EVENING ELECTRIC I DO A REIN PATIENTS WITH CO MORBID INSOMNIA WHICH I SHOULD MENTION DERIVES FROM A LARGER CLINICAL RILE LED BY MICHAEL SMITH AND HERE WE OBSERVED THAT BOTH LOWER TOTE SLEEP TIME AND HIGHER NUMBER OF MINUTES SPENT AWAKE AFTER SLEEP ONSET OR WHAT WE CALL LASO PREDICTED LOWER POSITIVE EFFECT THE NEXT MORNING AND THAT LED TO HIRE DAILY PAIN SEVERITY RATED IN THE EVENING AND A SIMILAR EFFECT FOR PAIN EXACT AROUNDLY AND THEY SHARE VARIANTS AND NOTABLY HERE, WE SEE ALTHOUGH THE SLEEP MEASURES WERE PRO DICK TIVE OF NEXT MORNING NEGATIVE AFFECT OF STATES, THOSE ASSOCIATIONS DIDN'T TRANSLATE INTO HIGHER PAIN SO IT WAS THROUGH POSITIVE BUT NOT NEGATIVE EFFECT. IN THIS ANALYSIS, THEY FLIPPED THE QUESTION AROUND A BIT. INSTEAD OF LOOKING AT SLEEP ON AFFECT, SHE ASKED WHETHER TRAIT LEVELS OF POSITIVE EFFECT WERE PROTECTIVE AGAINST THE EFFECT OF SLEEP DIS RISK ON NEXT DAY INFLAMMATION WHICH AS Dr. SAWSAN AS-SANIE JUST EXPLAINED IS ANOTHER RISK FACTOR FOR PAIN. AND AGAIN THESE WERE OTHERWISE HEALTHY PARTICIPANTS UNDERGOING A NIGHT OF NORMAL SLEEP AND A NIGHT OF FORCED AWAKENINGS AND WE SEE THAT SLEEP DISRUPTION LED TO INCREASED CELLULAR EXPRESSION OF THE CYTOKINES IL6 AND TNF ALPHA AS WELL AS THEIR CO EXPRESSION BUT IT HAPPENED ONLY AMONG PARTICIPANTS WITH LOW LEVELS OF POSITIVE AFFECT. SO IN THIS CASE, HAVING HIGHER TRAIT POSITIVE EFFECT WAS PROTECTED AND IT BUFFERED AGAINST THE EFFECT OF SLEEP DISRUPTION ON INFLAMMATION AND THIS PERHAPS REPRESENTS ANOTHER MECHANISTIC PATHWAY TO CON ACCEPT TYPEACTUALIZE IN THE BROT OF SLEEP AND PAIN. SO ANOTHER RELATED MECHANISM WE'VE BEEN INTERESTED IN IS AFFECTIVE PAIN MODULATION OR THE DEGREE TO WHICH AFFECTIVE STIMULI ALTER PAIN PROCESSING THAT BEHAVIORAL AND NEURO BIOLOGICAL LEVELS. IN OUR STUDY, WE ASKED WHETHER FORCED AWAKENINGS ALTERED THE BUILT OF POSITIVE EFFECT TO INHIBIT PAIN SO WE EXPOSED PARTICIPANTS TO A STANDARD AFFECTIVE PAIN MODULATION TASK IN WHICH THEY VIEWED POSITIVE AND NEGATIVE OR NEUTRAL SLIDES THAT WERE PAIRED WITH STIMULI AND THEY RAIDED THE PAIN ASSOCIATED WITH THE STIMULI. AND UNDER NORMAL SLEEP, WE SEE THE CLASSIC EFFECTIVE PAIN MODULATION OCCUR AND IN THIS CASE, PAIN IS LOWER UNDER CONDITIONS OF POSITIVE RELATIVE TO NEUTRAL OR NEGATIVE EFFECT OF STIMULI AND FOLLOWING FORCED AWAKENINGS, THAT CURVE FLATTENS SO WE SEE ESSENTIALLY ANNA ABOLISHMENT. NEXT SLIDE. I THINK IT'S IMPORTANT TO NOTE THAT THIS PATTERN FINDINGS THAT WE OBSERVED UNDER CONTROLLED CONDITIONS ALMOST DIRECTLY MIRRORS EFFECTS THAT JAMIE RUDY'S GROUP OBSERVED IN BETWEEN GROUP ANALYSIS OF HEALTHY SUBJECTS AND INDIVIDUALS WITH MODERATE TO HIGH INSOMNIA SO THESE DATA TELL US THAT SLEEP DISTURBANCES NOT ONLY ATTENUATE POSITIVE EFFECT LEVELS BUT ALSO THE FUNCTION OF POSITIVE AFFECT TO INHIBIT PAIN. SO FINALLY, I'D LIKE TO HIGHLIGHT THAT THE AFFECTS THAT HAVE JUST BEEN TALKED ABOUT, APPEAR TO BE TIED TO FUNCTIONING WITHIN THE MESS OWE CORTICAL REWARDS SYSTEM. AND IN OUR EXPERIMENTAL WORK AGAIN, FOR EXAMPLE, WE'VE EXAMINED SLEEP DISRUPTION ON REWARD RESPONSIVENESS AND IN THIS TASK, WE KNOW IT TO BE QUITE SENSITIVE TO VARIATION IN REWARD SYSTEMS FUNCTION AND PARTICULARLY CHANGES IN DOPAMINE ACTIVITY AND IT'S BEEN SHOWN TO DIFFERENTIATE PATIENTS WITH DEPRESSION FROM CONTROLS. ESSENTIALLY PARTICIPANTS ARE TASKED WITH DISCRIMINATING BETWEEN TWO NEARLY IDENTICAL STIMULI BUT THEIR DISPROPORTIONATELY REWARDED FOR CORRECT RESPONSES ATTRIBUTED TO ONE OF THE STIMULI. OVER TIME, PEOPLE WILL DEVELOP A BUY AS TOWARDS THE STIMULUS THAT'S REWARDED MORE FREQUENTLY. PATIENTS CAN DEPRESSION, FOR EXAMPLE, SHOW DIMINISHED REWARD RESPONSIVENESS AND THIS PRESENTS AS A FLATTER SLOPE OF CHANGE IN REWARD RESPONSE BIAS OVER BLOCKS OF THE TASK. SO, IN OUR SLEEP DISRUPTION STUDY WE SHOWED THAT POSITIVE EFFECTIVE CHANGES FOLLOWING SLEEP DISRUPTIONS, ESSENTIALLY DICTATED THE PATTERNS OF REWARD RESPONSIVENESS THAT WE ZO OBSER. THOSE WHO HAVE POSITIVE EFFECTIVE DEFICITS SHOWED IN REWARD RESPONSIVENESS FOLLOWING SLEEP DISRUPTION BUT THOSE ABLE TO MAINTAIN POSITIVE LEVELS SHOWED AN INCREASE IN REWARD RESPONSIVENESS FOLLOWING SLEEP DISRUPTION AND THIS CAN BE HIGHLIGHTS THE DEGREE OF INTEGRATION BETWEEN SLEEP LOSS AND EFFECTIVE FUNCTION AND THE REWARDS SYSTEM. NEXT SLIDE. NOW, WE OBSERVED AN INCREASE REWARD RESPONSIVENESS AFTER SLEEP DISRUPTION AMONG THOSE WHO RE MAY DESCRIBE AS RESILIENT INDIVIDUALS. THOSE WHO WERE ABLE TO PRESERVE POSITIVE EFFECT IN THE FACE OF ACUTE SLEEP LOSS. PRIOR WORK HAS ALSO SHOWN THAT SLEEP LOSS UNDER CERTAIN CONDITIONS IS ASSOCIATED WITH AN INCREASE IN FUNCTION AND POSITIVE SYSTEMS. AND FOR EXAMPLE, A STUDY BY MATTHEW WALK ARE'S GROUP SHOWED THAT HEALTHY INDIVIDUALS INTENDED TO SHOW A BUY AS FOR POSITIVE EMOTION APPRAISALS FOLLOWING TOTAL SLEEP DEPRIVATION WHICH THEN CORRESPONDED TO VARIATION IN CORTICAL BRAIN REGIONS THAT BROADLY FALL INTO A REWARD NETWORK. GETS THE BACKDROP OF WORK IT'S IMPORTANT TO CONTEXTUALIZE THESE TYPES OF FINDINGS WITH INDIVIDUAL DIFFERENCES IN LEVELS AND THE STABILITY OF POSITIVE EMOTIONS. WHICH IN OUR STUDY REVEALED IMPORTANT SUBGROUPS OF RESPONDERS. SO, FINALLY, HOW DO THESE REWARD RELATED FINDINGS INFORM OUR UNDERSTANDING OF SLEEP AND PAIN? SO TO ADDRESS THAT QUESTION, IN COLLABORATION WITH MY GOOD FRIEND AND COLLEAGUE DAVID, WE DEVELOPED A REWARDING MUSIC TASK AND WHICH PARTICIPANTS WERE EXPOSED TO A SERIES OF PERSONALLY MEANINGFUL SONG CLIPS THAT HAD HIGH LEVELS OF POSITIVE EFFECTIVE OR SONG CLIPS RATED NEUTRAL WITH NO PERSONAL SIGNIFICANCE. WE PAIRED THESE SONGS WITH A RAMP AND HOLD NOXIOUS TERMAL STIMULATION PARADIGM RAMPING TEMPERATURES UP TO A PAINFUL LEVEL. WE DID THIS IN A MRI MACHINE AND OBTAINED SCANS WHILE THEY WERE EXPOSED TO THESE REWARDING OR NEUTRAL STIMULI AND PAIN. >> TWO MINUTE WARNING. >> AND FURTHER PARTICIPANTS DID THIS TASK AFTER A NIGHT OF NORMAL SLEEP AND AFTER A NIGHT OF SLEEP DISRUPTION. WE FOUND FIRST THAT THE SUB WAS AK TA RATE IS BID REWARDING MUSIC AND IT WAS STRONGLY AK TA RATE ISED BY THE ONSET OF PAINFUL THERMAL STIMULI AND REWARDING MUSIC A LOT ERT NUCLEUS ACTIVITY WITH KEY NODES OF THE CIRCUITS AND ALSO DURING PAIN ONSET AND SLEEP DISRUPTION ATTENUATED THE ACTIVATION AND THE ANTERIOR MID SINGULAR CORTEX ALSO A PAIN ONSET. WE WERE INTERPRET THIS, ONE POSSIBLE INTERPRETATION OF THE INCREASED REWARD RELATED CONNECTIVITY BETWEEN THE NAC AND THE AMCC COULD BE THAT IT'S REFLECTIVE OF A RECRUITMENT OF THIS REGISTER ON TO RECOVER COGNITIVE CONTROL OF PAIN FOLLOWING SLEEP DISRUPTION. SO, TO SUMMARIZE, WE SEE THAT SLEEP DISRUPTION MODULATES POSITIVE EFFECT AND POSITIVE EFFECT OF PAIN AND NOT JUST AT BEHAVIORAL LEVEL BUT ALSO OBSERVABLE VIA CHANGES IN ACTIVITY WITHIN THE CIRCUITS. THESE FINDINGS SUPPORT THE MULTI SYSTEM VIEW OF THE SLEEP AFFECT AND PAIN DYNAMIC AND POINT TO POSSIBLE AREAS FOR FURTHER WORK TO INFORM FOR EXAMPLE NEURO MODULATORY THERAPEUTICS OR PSYCHOSOCIAL INTERVENTION TO BOOST POSITIVE EFFECT AND THE FACE OF SLEEP LOSS. AND WE COMPLETED A STUDY OF A BRIEF POSITIVE EMOTION SAVORING MEDICATION THAT I'D LIKE TO TALK ABOUT IF WE HAD MORE TIME BUT THERE ARE OF COURSE NUMEROUS AVS TO TRAVEL AND IT'S MY BELIEVE AND WE MAINTAIN A FRAMEWORK FOR UNRATTLING THE ASSOCIATION BETWEEN SLEEP AND PAIN WE'LL DRAW CLOSER TO DISCOVERING AN INTERVENTION THAT OPTIMIZES THE WHOLE PERSON AND TARGETS OUTCOMES BEYOND PAIN SEVERITY. >> TIME HAS EXPIRED. >> SO, THAT'S ALL I HAVE FOR YOU. THANK YOU SO MUCH. AND I CAN'T WITHOUT ACKNOWLEDGING THE POSTDOC TO BAL FELLOWS AND THE COORDINATORS WHO MAKE THIS WORK AND OF COURSE THE SUPPORT WE'VE FROM THE NIH PARTICULARLY NCCIH, NIADA. THANK YOU FOR YOUR TIME AND I WILL TRANSITION NOW TO Dr. ILGEN WHO IS NEXT. >> GREAT. THANK YOU. AND THANK YOU TO THE PAIN CON COR SLUM TO PRESENT TODAY. I'M GOING TO TALK ABOUT THE OVERLAP BETWEEN CHRONIC PAIN AND SUBSTANCE USE DISORDERS AS WELL AS RESOLVED FROM -- MAYBE SUBSTANCE USE DISORDERS AND SUBSTANCE RELATED ADVERSE EVENTS AMONG THOSE WITH CHRONIC PAIN. FOR TODAY'S TALK, WE'RE GOING TO KIND OF FLIP THAT A LITTLE BIT AND TALK ABOUT INDIVIDUALS WHO HAVE ESTABLISHED SUBSTANCE USE DISORDERS AND WHAT CAN BE DONE ABOUT THE LARGE GROUP OF FOLKS WHO HAVE CHRONIC PAIN AND COULD BENEFIT FROM SOME ADDITIONAL TREATMENT. UNFORTUNATELY, ESPECIALLY WITHIN SPECIALTY SUBSTANCE USE DISORDER TREATMENT PROGRAMS, THOSE WITH CHRONIC PAIN ARE OFTEN THEY ARE OFTEN GIVEN LITTLE IN TERMS OF GATE AN ABOUT HOW TO BERMAN AGE THEIR PAIN AND SO THAT IS SOMETHING WE'VE BEEN LOOKING AT AND I'LL TALK ABOUT OUR RESEARCH ON INTERVENTIONS TO EMIGRATED DISCUSSIONS OF PAIN AND SUBSTANCE ABUSE DISORDERS. IN ELSE TERMS OF ACKNOWLEDGMEND DISCLOSURE I WILL FOCUS ON OUR RESEARCH FUNDED BIT V.A. AND AS WELL AS NIADA AND I'LL TOUCH ON AN ONGOING STUDY FROM NCCIH AND I'M A PART OF A SMALL COMPANY AND I DON'T THINK IT'S RELATE TODAY THIS CONTENT BUT I WANT TO MAKE SURE THAT OTHERS ARE AWARE. SO, YOU CAN GO AHEAD AND ADVANCE. >> CHRONIC PAIN IS HIGHLY COMMON IN ADDICTION SETTINGS. 50% TO 80% SHOWING UP TO DRUG AND ALCOHOL TREATMENT REPORT SOME TYPE OF PERSISTENT AND DEBILITATING PAIN. THE GENERAL RULE OF THUMB IS THAT THE MORE THAT THE SUBSTANCE USE DISORDER TREATMENT SETTING FOCUSES ON OPIOID USE DISORDERS THE MORE COMMON THE CHRONIC PAIN CONDITION IS SO FUR LOOKING AT MAINTENANCE PROGRAMS OR MEDICATION TREATMENTS FOR OPIOID USE DISORDERS, YOU CAN SEE RATES OF CO OCCURRING PAIN THAT APPROACH 80%. AND WHEN PAIN IS PRESENT, OBSERVATIONAL DATA INDICATES THAT IT IS ASSOCIATED WITH POORER TREATMENT OUTCOMES, NOT JUST IN TERMS OF PAIN AND FUNCTIONING BUT ALSO IN TERMS OF GREATER LIKELY HOOD OF POOR SUBSTANCE RELATED OUTCOMES UP TO ONE YEAR OF POST TREATMENT. UNFORTUNATELY, PAIN IS RARELY COMPREHENSIVELY ADDRESSED DURING STANDARD S.U.V. TREATMENT WHICH RAISES THE POSSIBILITY THAT POTENTIALLY IMPROVING PAIN TREATMENT DURING SUD TREATMENT COULD LEAD TO BETTER OUTCOMES TO PAIN AND SUBSTANCE USE DISORDERS AND THERE'S SOME RESEARCH ON THIS TOPIC INCLUDING PROBABLY MOST DIS BLEE ERIC GARLAND AND COLLEAGUES WORK ON MINDFULNESS BASED INTERVENTIONS AND THESE ARE CONDUCTED IN AN SUD SETTINGS BUT IN GENERAL FOR THEIR PATIENTS WHO HAVE CHRONIC PAIN AND EMERGING SUBSTANCES THERE'S A SENSE THAT INTERVENTION CAN IMPROVE OUTCOMES IN BOTH OF THOSE DOMAINS AND I'LL TALK ABOUT A FEW TRIALS THAT WE'VE DONE IN A SIMILAR VANE. NEXT SLIDE, PLEASE. OUR WORK USES A COMBINATION OF A COGNITIVE BEHAVIORAL MODEL FOR THINKING ABOUT CHRONIC PAIN AND FOR THINK WE THINK OF SUBSTANCE USE AND THOUGHTS AND PERCEPTIONS OF SUBSTANCE USE FIGHTING NICELY IN A CHRONIC PAIN FOR A LONG TIME LIKE THE FEAR AVOIDANCE MODEL. FEARS ABOUT PAIN CONCERNS ABOUT THE INABILITY TO MANAGE PAIN AND EXPECTANCY AROUND SUBSTANCE USE CAN PERPETUATE AVOIDANCE OF POTENTIALLY PAINFUL STIMULI AS WELL AS THE USE OF SUBSTANCES TO COPE AS AVOIDANCE COPING MECHANISM AND THIS CAN KIND OF LEAD TO A SPIRAL OF NEGATIVE OUTCOMES THAT CHARACTERIZE CHRONIC PAIN AND FROM AN INTERVENTION PERSPECTIVE, YOU ARE LOOKING TO HELP SHAPE PERCEPTIONS OF PAIN AND SUBSTANCE OF USE AS WELL AS ENGAGEMENT IN FEWER AVOIDANCE RELATED BEHAVIORS INCLUDING SUBSTANCE USE AND MISUSE AS A WAY TO BREAK OUT OF THAT CYCLE. NEXT SLIDE. PLEASE. WE DEVELOPED THIS INTERVENTION AND WE CALL IT IMPACT AND IT'S THE BASIS OF WHAT I'LL DESCRIBE HERE TODAY AND THIS IS SOMETHING THAT CAN BE OVER LAID ON TO AN EPISODE OF EXISTING SUBSTANCE USE DISORDER TREATMENT AND IT'S MEANT TO BE COMPLIMENTARY TO A LOT OF MESSAGES THAT WE WILL RECEIVE IN STAND AR ADDICTION TREATMENT AND IT HIGHLIGHTS THOSE LINKS BETWEEN SUBSTANCE USE AND CHRONIC PAIN THROUGHOUT AND ENCOURAGES DIFFERENT COPES OF COPING WITH NEGATIVE THOUGHTS OF PAIN AND NEGATIVE EXPERIENCES SUCH AS SPIKES IN PAIN. SO, FOR TODAY, I AM GOING TO DESCRIBE THE RESULTS OF TWO RANDOMIZED TRIALS BOTH OF THE SAME INTERVENTION. THE FIRST OF WHICH WAS CONDUCTED IN THE V.A. AND IN AN OUT PATIENT SETTING, THE OTHER WAS CONDUCTED IN A COMMUNITY RESIDENTIAL DRUG AND ALCOHOL TREATMENT PROGRAM. NEXT SLIDE, PLEASE. SO FOR THE V.A. STUDY, WE RECRUITED 130 PATIENTS STARTING AN EPISODE OF VA TREATMENT THEY WERE RANDOMIZED TO ONE OF TWO 12-WEEK GROUPS AND IN THIS IMPACT INTERCEPTIONS AND OR ANNA TENSION MATCH CONTROL CONDITION THIS WAS REALLY JUST KIND OF A PSYCHO EDUCATIONAL CONTROL WHERE THEY MET WITH A THERAPIST AND OTHER PATIENTS FROM THE SAME LENGTH OF TIME AS THE INTERVENTION AND IT DID NOT OVERLAP IN TERMS OF THE SPECIFIC CONTENT AND OUR FOLLOW-UP RATES WERE HIGH FOR THIS PATIENT POPULATION. NEXT SLIDE, PLEASE. NET CONSISTENTLY LOWER PAIN OVER THE FOLLOW-UP INTERVAL COMPARED TO THOSE RANDOMIZED TO THE CONTROL CONDITIONS AND YOU SEE THAT IN TERMS OF FUNCTIONING THEY REPORTED HIGHER FUNCTIONING ON AVERAGE AND DID THOSE IN THE LOCAL CONDITION OVER THE 12-MONTH FOLLOW-UP. NEXT SLIDE, PLEASE. TURNING TO SUBSTANCE RELATED OUTCOMES, THE UPPER LAST CORNER AND WE LOOKED AT ALCOHOL AND OTHER DRUG USE SEPARATELY FOR THIS STUDY AND IN TERMS OF COL USE YOU SEE THE NATIONAL FOLLOW-UP THE TWO CONDITIONS LOOK SIMILAR AND THERE'S NO DIFFERENCE THERE AND THEN OVER TIME, A DIFFERENCE EMERGES WHERE THOSE IN THE CONTROL CONDITIONS AND RETURNED TO MORE REGULAR ALCOHOL USE WHERE THOSE IN THE INITIALLY FOLLOWING TREATMENT. AND IN THE BOTTOM RIGHT-HAND CORNER LOOKING AT YOU SEE THE WIDER OR BARS AND WE HAD A LOT OF OVER HAPPEN BETWEEN CONDITIONS AND NO REAL VERSUS THE CONTROL CONDITION. AS THE LAST SLIDE OF THIS TRIAL, THIS IS A KEY MECHANISM OF THE INTERVENTION AND YOU CAN SEE CONSISTENCES FOR CONDITIONS FOR THOSE IN THE CBT OR IMPACT CONDITION AND NEXT SLIDE, PLEASE, SO TURNING TO THE NON V.A. STUDY THEY WERE CREATED DURING AN EPISODE OF COMMUNITY RESIDENTIAL DRUG AND ALCOHOL TREATMENT IN LARGE TREATMENT UNIT IN THE DETROIT AREA MICHIGAN AND WE TRIED TO RECRUIT MEN AND WOMEN INTO THIS TRIAL AND THEY WERE RANDOMIZED TO THE SAME CAN'T WE SHORT END THE CONDITIONS AND MET MORE FREQUENTLY WHERE WE DELIVERED THEM TWICE A WEEK AND WE FOLLOWED FOLKS FOR THREE, SIX AND 12 MONTHS AND AGAIN YOU CAN SEE THE FOLLOW-UP RATES. ADDITION TO THE PAIN LEVEL FUNCTIONING ALCOHOL USE AND DRUG USE FREQUENCY, WE HAVE A MEASURE OF PAIN TASK AND WE LOOKED AT PAIN TOLLENNANCE IN THIS STUFF. NEXT SLIDE, PLEASE. THE RESULTS ARE LESS IMPRESSIVE. WE SEE DIFFERENCES ON TWO OF THEM AND THOSE WOULD BE ENTA INDICATION OF HIGHER PAIN FUNCTIONING OVER THE FOLLOW-UP INTERVAL AND HIGHER PAIN DOLL ORANCE AND THERE WAS NO DIFFERENCES ON SELF-REPORTED PAIN LEVEL AND ALCOHOL USE AND DRUG USE. AS A ANALYSIS GETTING OUR HEAD AROUND WHAT IS MAYBE DIFFERENT BETWEEN THIS STUDY AND THE PRIOR STUDY WE EXAMINED SELF-EFFICACY YOU SAW IN ONE OF THE LAST SLIDES ON IT DOES DIFFER BY CONDITION AND WE SEE THAT THE ASSOCIATION BETWEEN SELF-EFFICACY AND PAIN LEVEL AND PAIN LEVEL FUNCTIONING OVER THE FOLLOW-UP INTERVAL BUT NO LINK BETWEEN THAT MEASURE AND THE ALCOHOL AND DRUG RELATED OUTCOME SHOWING THERE'S POPULATION OF PATIENTS AND EVEN THOUGH THEY FEEL BETTER THEY GET THE BEHAVIORAL PAIN MANAGEMENT INVENTION AND THEY'RE NOT NECESSARILY BEHAVING DIFFERENTLY IN TERMS OF THEIR SUBSTANCE USE AND ONE FINAL POINT IS THAT OUR FINDINGS WERE GENERALLY LARGER IN THOSE NOT IN THE CONTROLLED ENVIRONMENT. ONE, CHALLENGE IN THE PATIENT POPULATION WE WERE FOCUSING ON IS THAT MANY OF THE PEOPLE RECRUITED INTO THE STUDY WERE HOMELESS AND HAD UNSTABLE HOUSING FOLLOWING TREATMENT AND OFTEN THEY ENDED UP IN ENDED UP IN JAIL OR PRISON SO IT WAS DIFFICULT TO DETECT EFFECTS WITH THEY WERE NOT OUT IN THE COMMUNITY AND IF WE LIMIT OURSELVES TO THOSE PARTICIPANTS WHO WHEN THEY LEFT TREATMENT, SOME OF THE FINDINGS WERE A LITTLE MORE CONSISTENT AND ENCOURAGING. >> TWO MINUTES REMAINING. >> THANK YOU. SO AS A WRAP-UP, WE BELIEVE THAT NON MEDICATION TREATMENT HAVE A ROLE TO REPLY IN ADDRESSING PAIN IN THOSE WITH SUBSTANCE USE DISORDERS AND THOSE IN TREATMENT. I DIDN'T TALK ABOUT THE INFORMAL TREATMENT BUT THEY WERE REALLY APPRECIATIVE AND WE WERE ASKING ABOUT THEIR PAIN AND VALIDATING THE IMPORTANCE AND WORKING WITH THEM TO DEVELOP SOLUTIONS TO THEIR PAIN THAT WAS VERY DIFFERENT FROM WHAT MIGHT BE DRUG AND ALCOHOL AND THEY ATTEND RATES WERE VERY GOOD FOR OUR GROUPS AND THEY SEEMED REALLY ENGLISH GAGEDREAL --ENGAGE IN T. RESULTS WERE ENCOURAGING ESPECIALLY AROUND THE PAIN OUTCOMES AND THEY WERE LESSEN COURAGING AND WE DID SEE EVIDENCE THE MECHANISMS OF ACTION OF THE INTERVENTIONS WERE CHANGING IN THE CONDITION AND THESE FACTORS RELATED TO SELF-ADVOCACY AND THE GENERAL ABILITY TO COPE WITH PAIN ARE IMPORTANT AND THEY ARE CLOSELY LINKED WITH THE PAIN OUTCOMES THAN THE SUBSTANCE ELATED OUTCOMES SO WHAT IS THAT LINK BETWEEN PAIN AND WHAT CAN BE DONE TO HELP PATIENTS HAVE BETTER OUTCOMES. AND BOTH OF THESE STUDIES DID AND NA IS PROBABLY PARTICULARLY TRUE FOR THOSE WITH OPIOID USE DISORDERS SO WE ARE DOING FOLLOW UM TREATMENT TO SEE IF THAT TYPE OF INTERVENTION CAN HELP IMPROVE OUTCOMES IN THAT GROUP. NEXT SLIDE, PLEASE. THAT'S IT FOR MY PRESENTATION. WE'LL GO AHEAD AND HAND OFF TO THE NEXT PRESENTER. >> THANK YOU FOR HAVING ME HERE TODAY. MESH SLIDE, PLEASE. I HAVE PREVIOUS RESEARCH BUT NOT RELATED TO THIS PRESENTATION. WHEN WE THINK ABOUT CHRONIC OROFACIAL PAIN YOU THINK ABOUT DISORDERS BUT THEY CAN BE SUBDIVIDED TO NEURO VASCULAR PAIN AND IT'S A TERM EMBRACING A GROUP OF MUSCULAR SKILL TAP AND JOINT PAIN INFLAMMATORY OR A COMBINATION THEY MAY HAVE DIFFERENT DIRECTORY. THEY LOOKED AT FOUR OTHER PAIN CONDITIONS. FIBROMYALGIA, LOW BACK PAIN, IBR AND HEADACHES. YOU SEE THIS IN 2020 AND SHOWING IN RED PAINFUL AREAS AND IN BLUE AREAS THAT ARE NOT PAINFUL AND PATIENT WITH FINAL MYALGIA, LOW BACK PAIN, IRB AND HEADACHE AND YOU CAN SEE THAT THE RED PAINFUL AREAS EXTEND IN THE PATIENT BEYOND THE OROFACIAL REGION AND THE PATIENT WITHOUT THE CHRONIC PAIN CONDITION REPORT PAIN IN THE REGIS REGION AS WELL. AND NOW THE VERY COMMON PAIN OR CHRONIC PAIN THAT WE SEE IN THE OR OFFICIAL PAIN CLINICS IS PAINFUL POST DRAMATIC NEWER ON THEE AND IT'S TO THE OROFACIAL REGION AND IT CAN FOLLOW A DENTAL PROCEDURE LIKE SURGERY, IMPLANTS BUT IN CERTAIN PATIENTS IN SOME PATIENTS IT MAY FOLLOW WITH DENTAL PROCEDURES SUCH AS CROWN PREPARATION, EVEN CLEANING, SCALING AND MORE THAN ANOTHER CONDITIONS IN THERAPY A ROOT CANAL TREATMENT. AND IT'S SURPRISING THAT FIVE TO SEVEN HAVE SUCCESSFUL ROOT CANAL TREATMENT WITH NO COMPLICATION AND THIS IS A MILD PAIN AND IT MAY LAST SEVERAL YEARS FOLLOWING THE COMPLETION. NEXT. THE GOOD NEWS THAT OVER ALL PERSISTENT PAINFUL AND AREAS IS SIGNIFICANT LESS COMMON THAN PAIN FALLING SPINAL NERVE INJURY. IT'S GO AHEAD NEWS BECAUSE IT'S DENTIST MOST PROCEDURES THAT WE DO CAN CAUSE TRAUMA TO THE AREA AND THE QUESTION THAT HE WAS ASKED, WHY SOME IS MORE RESISTANT AND ONE THING WE TALK ABOUT IS THE ONLY AREA THAT IS PROGRAM FOR THE INNOVATION AND ONE SET OF REPLACING THE OTHER AND ANOTHER POINT IS RELATED TO THE INJURY BARRAGE AND IT'S BEEN SHOWN THAT THE INJURY BARRAGE INCIDENTS IS MUCH LOWER COMPARED TO THE CONSUMPTION AND IN ADDITION, MOST OF THE PROCEDURES IN THE OFFICE OF THE LOCAL ANESTHESIAIA THAT AND IT REPORTED THAT THIS SPROUT THAT ARE FOUND FOLLOWING NERVE INJURIES IS NERVE SECTION ARE HARDLY PRESENT OR NOT PRESENT AT ALL FOLLOWING THE TRANCE SECTION. AND A RECENT STUDY FROM OUR GROUP, DEMONSTRATED DIFFERENT GENE EXPRESSION IN THE DOSAL ROOT GANGLION AND THIS IS IMPORTANT BECAUSE IF WE SAY THAT THE SYSTEM IS MORE RESISTANT TO CHRONIC PAIN, FINDING MAY HELP AND DOWN THE ROAD EVEN POTENTIAL TREATMENT. OF COURSE, THE VERY INTERESTING QUESTION IS, WHAT IS MAKING SOME PATIENTS DEVELOP CHRONIC PAIN FOLLOWING INJURY AND SOME TO DEVELOP ONLY ACUTE PAIN THAT HEALS? OF COURSE, IT'S AN IMPORTANT ROLE IS GENETICS AND PSYCHOLOGICAL FACTORS ARE SIGNIFICANT AND WE MENTIONED ALREADY THE SYMPATHETIC NERVOUS SYSTEM AND INFLAMMATION WE'VE ZONE IN STUDIES AND I WOULD LIKE TO FOCUS ON THE ROLE OF PAIN MODULATION. TO TRY TO DEFINE IT IS DIFFICULT AND WE WILL SUMMARIZE AND SAY THAT THE CENTRAL NERVOUS SYSTEM WILL MODULATE PAIN THROUGH EX CITATION AND WE CAN TEST IT WITH SUMMATION AND IT'S A TEST HOW DO WE DO THAT WE APPLY A PAINFUL STIMULUS AND REPORT THE INTENSITY AS CAN YOU SEE ON THE RED BARON THE RIGHT. AND SYSTEMS WE WILL NOT SEE THE SAME REDUCTION IN PAIN SENSITIVITY AND THERE'S ARE A LOT OF STUDIES TO SHOW IS THAT LESS EFFICIENT THEY ARE ON LIMITED TO A NUMBER OF STUDY FOCUSES ON THE OROFACIAL REGION. IN THAT ALL, WE COMBINED SUMMATION AND CTM AND WE USE 30 REPEATED MECHANICAL STINZIANO YOU EYE AND THEN WE SECRETARY PATIENT TO REPORT AGAIN INTENSITY FOLLOWING THE FIRST 10, 20 OR 30 STIMULI THAT CAN BE DONE OBVIOUSLY WE GET SUMMATION AND THE CONTINUING PAIN FALL STIMULATION CAN SEE HERE AND REDUCE THE PAINENS TENSE TEE AND WE TESTED PAIN FOLLOWING ROOT CANAL AND THE MOST COMMON DENTAL PROCEDURE AND IN BLUE AND WE CAN SEE THE PAIN AND MINIMUM PESK O AND WE CAN STEL THE STUDY AND THE PATIENTS THAT DEVELOPED CHRONIC PAIN TO BEGIN WITH AND LESS EFFICIENT PAIN POPULATION AND WE CAN CONCLUDE THAT SIMILAR TO OTHER CHRONIC PAIN CONTINUES, PATIENTS SUFFERING FROM CHRONIC PAIN FROM A ROOT CANAL HAVE LESS SUFFICIENT PAIN MODULATION. AND AS I MENTIONED EARLIER, EXERCISE IN HOWEVER, IT EFFECT IS LIMITED TO THE TIME OF THE CONDITIONING PAINFUL STIMULUS AND WHILE EXERCISE EFFECT CAN LAST BEYOND AND AFTER THE EXERCISE ENDED. AND IN OTHER STUDIES TO SHOW THAT THERE'S NOT A CORRELATION BETWEEN THE TWO PATIENTS WOULD HAVE EXCELLENT EXERCISE AND NOT NECESSARILY HAVE GOOD. NEXT. HERE IN THIS STUDY, WE USED EXERCISE TO COMPARE THE INHIBITOR SYSTEM OF PATIENT WITH CHRONIC MYALGIA WHICH IS SUBTYPE AND THEY CREATED TO PAIN AND HEALTHY CONTROLS. AND TO ACHIEVE EXERCISE IN HYPOAGLESIA THEY 50% OF THE MAXIMUM NUMBER OF STEPS THEY CAN HAVE IN ONE MINUTE AND SUB STUDIES ARE USING MORE INTENSE EXERCISES AND WE FOUND THAT MORE INTENSE EXERCISE REDUCED THE COMPLIANCE OF PATIENT THAT ALREADY HAVE CHRONIC PAIN. SO SIMILAR TO THE R ROOT CANAL - >> WE CAN CONCLUDE FROM THIS STUDY THAT PATIENTS HAVE LESS EFFICIENT PAIN AND EXERCISE AND HOWEVER THEY HAVE A DELAYED RESPONSE AND THE RESPONSE IS STILL EXISTING WE CAN USE THE TREATMENT IN THE FUTURE. NEXT, PLEASE. TO FURTHER STUDY EXERCISE AND WE WILL ANIMAL MODEL WHERE WE TESTED RODENTS SENSITIVITY TO MECHANICAL STIMULATION BEFORE AND AFTER THREE MINUTES ON A ROTATING ROLL AND YOU CAN SEE ON THE DRAFT, SOME DEVELOP SIGNIFIT AND SOME WERE MEANINGFUL AND THEY HAD MORE THAN 70% REDUCTION IN AT LEAST THREE REPEATED TESTS AND THEY HAVE VERY MINOR ARE LOWER THAN 30% REDUCTION IN AT LEAST REPEATED TESTS AND THOSE ARE THE SIGNIFICANT RATES THAT WE CONCEDED AND BY EXERCISING AND THOSE WITH MINUTE YUM AS LOW THAT HAVE LESS SUFFICIENT. NEXT. LOW AND HIGH IN PAIN POPULATION AND THE SIGH ATTIC AND TO SUMMARIZE THE RESULTS, LOW RATES DEVELOP SIGNIFICANTLY MORE PAINFUL NERVE INJURY AND THAT MEANS LOW LESS PAIN AND DEVELOP MORE PAIN. IN ADDICTION, LOW EIH RATS DEVELOPED PAIN IN THE CONTRA LATERAL UNEFFECTED NERVE TERRITORY BUT THAT WAS ONLY FOR SIGH ATTIC NERVE INJURY AND NOT THE, AND RELATION TO. WE FOUND THE MIRROR IMAGE IN HIGH EIH RATS ONLY IN THE SCIATIC NERVE THIS IS ANOTHER EXAMPLE OF THE SYSTEM RELATIVE RESISTANCE TO CHRONIC PAIN FOLLOWING INJURY. AND NEXT SLIDE. I THINK TO RESPECT THE TIME WE'LL SKIP THIS ONE. SKIP THIS SLIDE. ONE OF THE PROBLEMS WE HAVE IN THE OWE OFFICIAL PAIN CLINICS IN AND AND OUR TREATMENT IS TRIAL AND ERROR. PATIENTS WILL BENEFIT MORE FROM TREATMENT AND SO WHAT WE DID IS WE TREATED LOW AND HIGH EIH RATS STRONG AND WEAK PAIN SYSTEMS AND WITH A RANGE OF MEDICATION THAT ARE USED IN THE PAIN CLINIC AND WE DID IT AFTER FOLLOWING RAIN -- TO SUMMARIZETHE FINDING WE D LESS SUFFICIENT PAIN RELATED SYSTEM THEY HAD BENEFITED MORE FROM -- NEXT LIED, PLEASE. SO THE NEXT QUESTION THAT WE HAD WAS TO ASK OURSELVES, ARE THOSE MEDICATIONS THAT ARE SPECIFICALLY BETTER WITH PATIENTS AND THE REST THAT IT HAS LESS EFFICIENT PAIN, DO SOMETHING TO THEIR CLAIM OF RELATION -- >> A MINUTE WARNING. >> WE GAVE THOSE MEDICATIONS TO THE RATS TO LOW AND HIGH EIH RATS AND WE FOUND THAT FOUR DAYS OF TREATMENT TURNS FORM 70% OF THE LOW RATS THAT HAD LOW PAIN AND LOW EXERCISE INTO HIGH OR MEDIUM AND IT IMPROVES THAT PAIN OF RELATION SYSTEM AND THIS MAY HAVE A CLINICAL RELEVANCE. NEXT, PLEASE. MODEL THAT WAS DEVELOPED BY DAVID SUGGESTED THAT PATIENTS WITH LESS EFFICIENT PAIN OF RELATION RED IN THIS SLIDE AND ARE AT HIGH-RISK OF DEVELOPING CHRONIC PAIN AND BLUE IS REDUCED RATES OF CHRONIC PAIN SO IF PATIENTS ARE HAVING INJURY IN RED THEY WILL DEVELOP PERSISTENT PAIN. >> YOU ARE MUTED. >> YOU HAVE MUTED YOURSELF. HOW DID I DO THAT? NEXT, PLEASE. SO IF A PATIENT IS IN THE RED AREA, AND HE IS A PIE RISK OR SHE IS AT HIGH-RISK TO DEVELOP CHRONIC PAIN IF WE CAN IMPROVE BY THEY WERE PEE AND OR EXERCISE PROTOCOL, THE HOPE IS THAT THOSE PATIENTS WILL DEVELOP ACUTE PAIN BUT NOT A PERSIST APARTMENT PAI. TO SUMMARIZE WE CAN SAY THAT CHRONIC OR OFFICIAL PAIN ARE COMMON AND OPEN LAP WITH OTHER PAIN AND THE GENERAL SYSTEM IS MORE RESISTANT TO PAIN FOLLOWING INJURY AND INEFFICIENT PAIN MODULATION SYSTEM IS ASSOCIATED WITH CHRONIC PAIN AND IT MAY IMPROVE THE PAIN POPULATION SYSTEM. THANK YOU, VERY MUCH. >> THANK YOU. I BELIEVE WE ARE NOW GOING TO MOVE TO THE Q&A SESSION FOR THIS FIRST PANEL. THANK YOU WHO SUBMITTED QUESTIONS. I HAVE ONE FOR EVERYBODY. AND THEN WE'LL SEE HOW WE'RE DOING ON TIME. SO, Dr. KOEHLOMOOS. PAIN WITH MILITARY MEMBERS WITH POLYTRAUMA YOU DESCRIBED, IT APPEARS YOU ARE USING CBT OR MINDFUL LESS FOR THERAPY, HAS ANYONE ALREADY USED ACT ACCEPTANCE AND COMMITMENT THERAPY AS PART OF THE CARE PLAN? >> GREAT. THANK YOU FOR ASKING THAT QUESTION. I WAS ACTUALLY HOPING THAT WE WOULD GET TO TALK A LITTLE BIT ABOUT THE OR I ORLICULA AR ACUPO I WRITE THE ANONYMOUS POSTER OF THOSE QUESTIONS TO KNOW I'M HAPPY TO ADDRESS THAT LATER. I AM LESS CLEAR ON THE INTERVENTION THAT YOU MENTIONED. IT MIGHT BE BEING TESTED. WE DO A LOT OF EXPERIMENTATION. CLINICAL TRIALS OF DIFFERENT METHODS BOTH FUNDED BY THE DOD AND ALSO IN PARTNERSHIP WITH THE V.A. SO I'M NOT AWARE OF ANY TRIALS OF THAT BUT I WOULDN'T BE SURPRISED. THERE'S A LOT OF DIFFERENT -- FOR ANY OF YOU, FOR THOSE OF YOU WHO ARE ON THE CALL, IF YOU ARE RESEARCHERS, YOU KNOW, IF YOU DON'T KNOW THIS, I KNOW THAT MOST YOU LOOK TO THE NIH FOR FUNDING BUT YOU MIGHT LOOK TO CDMRP THE CONGRESSIONAL AND MEDICAL RESEARCH AND MATERIALS MRMC. WRITE TO ME AND I'LL LET YOU KNOW. WE HAVE FUNDING FOR A LOT OF THESE DIFFERENT THINGS. YOU DON'T NECESSARILY HAVE TO DO YOUR WORK ON A MILITARY POPULATION, ALTHOUGH IT'S NICE. BUT DO LET ME USE THIS AS AN OPPORTUNITY TO ATTRACT MORE TALENT TO ISSUES THAT ARE IMPORTANT TO THE DOD LIKE WHOLE PERSON HEALTH AND PAIN MANAGEMENT AND DIFFERENT INTERVENTIONS FOR BEHAVIORAL HEALTH DISORDERS SO THANK YOU. >> THANK YOU. Dr. SAWSAN AS-SANIE. WHAT ARE SOME CAUSES FOR SYSTEMATIC OR SYSTEMIC INFLAMMATION IN THE CONTEXT OF ENDOMETRIOSIS OR CHRONIC PELVIC PAIN? THERE WAS ANOTHER QUESTION ABOUT INVOLVEMENT OF A PATHOGENIC MICROBIOME? IS THERE ANYTHING CAN YOU SAY ABOUT THAT AND FOR A GIVEN PATIENT, IS THERE A SIMPLE WAY TO TELL IF THE PAIN IS NOCIPLASTIC. >> THOSE ARE ALL EXCELLENT QUESTIONS AND IN TERMS OF SYSTEMIC INFLAMMATION THERE'S ACTUALLY NOT A TREMENDOUS AMOUNT OF WORK THAT HAS BEEN DONE IN THAT AREA OF ENDOMETRIOSIS. MOST OF WHAT WE KNOW IS THAT A VERY STRONG LOCAL LEVELS OF LOCAL PELVIC INFLAMMATION AND THERE'S SOME DATA THAT SUGGESTS THIS EXTENDS TO A SYSTEMIC LEVEL BUT THE AMOUNT OF BODY OF EVIDENCE IN THAT IS A BIT MORE LIMITED AND THE RELATIONSHIP BETWEEN THE INFORMATION IS COMPLETELY UNKNOWN. WITH REGARDS -- I'M SORRY, THERE WERE THREE QUESTIONS. I FORGOT ALREADY THE SECOND ONE. >> PATHOGENIC MICROBIOME. >> AND YES, THERE'S VERY EARLY WORK LOOKING AT PATHOGENIC MICROBIOME BUT AGAIN, YOU KNOW, ITS RELATIONSHIP BETWEEN THESE OTHER FACTORS STILL REMAINS UNKNOWN AND SO IT'S WHERE WE ARE WITH RESEARCH AND REALLY JUST VERY SMALL MICROSCOPES IN DIFFERENT, YOU KNOW, AREAS OF DISEASE BUT NONE OF REALLY BEEN INTERCONNECTED YET. AND THEN THE THIRD QUESTION WAS, HOW DO WE MEASURE NOCIPLASTIC PAIN AND I WOULD SAY WHILE THERE'S A LOT OF REALLY EXCELLENT WORK THAT HAVE BEEN SCRUBBED BY ALL OF THESE INVESTIGATORS, ON WAYS TO MEASURE IT IN THE LAB WHEN WE ARE THINKING ABOUT IT CLINICALLY THEY'RE REALLY AREN'T STANDARDIZED WAYS OF PROBABLY I WOULD SAY THE BEST WAY BASED ON WHAT I HAVE LEARNED IF MY MEN STORES IS LOOKING AT A BODY MAP AND TRYING TO UNDERSTAND FROM A PATIENT WHAT ARE THE OTHER REGIONS IN THE BODY THAT THEY'VE EXPERIENCED PAIN AND THAT SAY PRETTY GOOD ROUGH ESTIMATE OF WHERE THEY ARE IN THAT SCALE. >> THANK YOU. DO ANY OF THE OTHER PANELISTS WANT TO CHIME IN. A WAY TO TELL DIFFERENT TYPES OF CHRONIC PAIN? >> ANY OTHER VIEWPOINTS. I'LL MOVE ON TO THE NEXT QUESTION. Dr. FINAN, HAVE YOU STUDIED AN ASSOCIATION OF PAIN AND SLEEP LOSS WITH COUPLES WHO HAVE YOUNG CHILDREN OR BABIES THAT LEAD TO SLEEP REDUCTION AND I'M ASKING PERSONALLY. DO POSTPARTUM CHANGES SEX DIFFERENCES BETWEEN MALES AND FEMALES AND IF SO DOES THIS SEX DIFFERENCE NEUTRALIZE OR GO BACK TO NO SIGNIFICANT DIFFERENCES AFTER A CERTAIN AMOUNT OF TIME? >> YEAH, SO, THAT'S A GREAT Q THE MODEL THAT WE USE EXPERIMENTALLY, ONE OF THE REASONS WE LOOK AT THIS FORCED NOCTURNAL AWAKENINGS PARADIGM IS BECAUSE REPEATED A -- AWAKENNES IS A HALLMARK OF SLEEP MAINTENANCE INSOMNIA IN PATIENTS WITH CHRONIC PAIN WHO MAY BE AWAKENED THROUGHOUT THE NIGHT BUT THEIR PAIN. IN THE EXPERIMENTAL CONTEXT, IT'S REALLY A GOOD BIT MORE SEVERE FROM AN AWAKENING STANDPOINT THAN PEOPLE WITH INCOM SOMNIA EXPERIENCE. IT'S OUR ABILITY TO KIND OF GENERALIZE THE CLINICAL POPULATIONS WITH ONE EXCEPTION, AND THAT IS HAVING A BABY IN THE HOUSE, PARTICULARLY IF YOU ARE A MOTHER, OR FATHER WHO IS DOING MIDDLE OF NIGHT CARE. SO, I'VE GOT A COUPLE YOUNG KIDS NOW AND SO I RECENTLY WENT THROUGH ALL OF THAT AND CAN SAY FOR SURE THAT OUR FORCED AWAKENINGS PARADIGM IS SIMILAR SO LOTS OF PEOPLE UNTIL THE REAL WORLD GO THROUGH EXTENDED PERIODS THAT ARE CONSIDER THEY EXPERIENCE SIMILAR THINGS THAT WE ARE DOING IN THE LAB. WHEN WE LOOK AT THE DATA, WE HAVE RECENTLY PUBLISHED SOME SEX DIFFERENCES IN RESPONSE TO THE FORCED AWAKENINGS PARADIGM AND ONE THAT WAS PARTICULARLY INTERESTING TO US WAS THAT FEMALES WERE ABLE TO -- THEY WERE MORE RESILIENT IN TERMS OF THEIR STAGE N3 SLEEP. THEIR SLOW WAVE SLEEP FOLLOWING THE FORCED AWAKENINGS PARADIGM AND IT'S SOMETHING THAT'S DIFFICULT TO LOOK AT IN MANY SLEEP DEPRIVATION PARADIGMS PARTICULARLY TOTAL SLEEP DEPRIVATION BECAUSE YOU DON'T HAVE THE OPPORTUNITY TO SEE IN THE COURSE OF THIS KIND OF SLEEP DISTURBANCE, WHAT IS HAPPENING IN YOUR SLEEP. THEY'RE SLEEP DOUGH, WE ALLOW PEOPLE TO FALL ASLEEP, WE WAKE THEM UP, ALLOW THEM TO FALL BACK ASLEEP OVER EIGHT HOURS SO WE ESSENTIALLY DEPRIVE THEM OF FOUR HOURS OF SLEEP AND WE CAN SEE WHAT IS GOING ON AND IN TERMS OF THEIR SLEEP EEG IN THE INTERIM AND WE SAW THAT FEMALES WERE BETTER ABLE TO PRESERVE SLOW WAVE SLEEP FOLLOWING A SLEEP LOSS. WE HAVEN'T FOLLOWED UP IN TERMS OF PAIN BUT IT'S A INITIAL FOLLOWING WE CAN GO OFF. >> VERY INTERESTING. Dr. ILGEN, HAVE YOU EXAMINED MODERATORS OF TREATMENT EFFICACY IN YOUR CBT TRIAL? PATIENT CHERER PHYSICS SUCH AS SEX DIFFERENCES? >> THEY LOOKED SOMEWHAT SIMILAR BUT WEAKER WHEN SPLIT OUT BY GENDER AND THEN, OUR BY SEX AND THAT WE REALLY DIDN'T SEE AN EMERGING PATTERN OF RESULTS THAT WAS ALL THAT COMPELLING AND OUR MAIN OUTCOME PAPER PRESENTED IT SEPARATELY IN MEN AND WOMEN FOR THE PRESENTATION TODAY. I GROUPED EVERYONE TOGETHER. WE'VE LOOKED AT A NUMBER OF DIFFERENT MODERATORS AND MY SENSE IS THAT THE DRIVERS OF CLINICAL OUTCOMES IN THIS GROUP HAVE A LOT TO DO WITH HOW PEOPLE LEAVE RESIDENTIAL TREATMENT AND MORE THAN HOW THEY LOOK WHEN THEY SHOW UP AT TREATMENT. THERE IS OBVIOUSLY RELATIONSHIP THERE AND THAT SOMEONE IS BASELINE CHARRER ADVE CHARACTERF THEY LEAVE AND GO TO JAIL AND GO IN THTHEY'RE HOMELESS, THEY HAVA DIFFERENT COURSE THAN PEOPLE THAT LEAVE AND GO TO A STABLE HOME ENVIRONMENT AND EXAMINING SUB GROUP DIFFERENCES WITHIN AN INTENT TO TREAT ANALYSIS AND RANDOMIZED TRIAL IS DIFFICULT BECAUSE YOU ARE TALKING ABOUT THINGS THAT HAPPENED POST BASELINE AND SO YOU REALLY DON'T KNOW THAT BASED ON HOW THEY LOOK WHEN THEY SHOW UP TO TREATMENT SO I THINK FOR US, YES, WE'VE EXAMINED MODERATORS BY IMPRESSIONIST THAT THE RESULTS ARE NOT ALL THAT INFORMATIVE IN ALL LICK LIKELIHOOD THEY HAVE HE POSITIVE AND NEGATIVE OUTCOMES IN IDENTIFYING WITCH FACTORS MATTER IN WHICH GROUPS AS THEY EXIT TREATMENT. >> A QUICK FOLLOW-UP, HOW DO YOU ATTRIBUTE YOUR EXCELLENT RETENTION RATES IN YOUR V.A. AND RESIDENTIAL STUDIES. WHY DO SO MANY PEOPLE FINISH THE TRIAL IN YOUR CASE? >> IT HELPS TO DELIVER AN INTERVENTION DURING RESIDENTIAL TREATMENT BECAUSE PEOPLE ARE THERE AND THEY'RE GOING TO DO YOUR TREATMENT AND ADHERE TO YOUR PROTOCOL. IN TERMS OF POST TREATMENT FOLLOW-UP RATES IN THE V.A. FOR THOSE PEOPLE ON THE CALL WHO DO V.A. RESEARCH YOU KNOW THAT THE ELECTRONIC MEDICAL RECORDS IS A GREAT RESOURCE AND WE'RE ABLE TO TRACK PEOPLE. THANK YOU TO ALL THE SPEAKERS FROM THE FIRST SESSION. I REALLY APPRECIATE THE CHANCE TO MODERATE AND FEEL IS FREE TO LEAVE THE QUESTIONS IN THE Q AND A AND WE'LL GET THEM TO THE SPEAKERS. >>ON BEHALF OF THE ORGANIZERS, I'D LIKE TO APOLOGIZE FOR THIS TECHNICAL GLITCH AND HOPEFULLY WE'LL RESOLVE ALL THE ISSUES DURING THE BREAK. THANK YOU VERY MUCH AND THANK YOU TO ALL THE SPEAKERS OF THE WONDERFUL PANEL AND WE STILL HAVE UNANSWERED QUESTIONS SO WE WILL BE GLAD TO REJOIN WITH OUR SPEAKERS DURING THE NEXT WORKING SESSION TOMORROW AT 3:45 AND NOW WE'LL HAVE A 30-MINUTE BREAK >>IT'S MY PLEASURE TO WELCOME YOU BACK FROM THE BREAK. FOR THOSE WHO GOT CUT OFF FROM THE BREAK, ACCEPT OUR SINCERE APOLOGIES FOR THE TECHNICAL GLITCH. HOPEFULLY THE REST OF THE MEETING WILL GO SMOOTHLY. "HOPE EVERYONE TOOK ADVANTAGE OF THIS TIME TO STRETCH YOUR LEGS AND GET NOURISHMENT. WE HAVE A FULL AGENDA TODAY, WE WILL GET STARTED. NEXT IS LAURA WANDNER. A PROGRAM DIRECTOR IN THE OFFICE OF PAIN POLICY AND PLANNING AT THE NATIONAL INSTITUTE OF NEUROLOGICAL DISORDERS AND STROKE. SHE MANAGING PROGRAMS WITHIN THE ACUTE TO CHRONIC PAIN PROGRAM AND THE HELP TO END ADDICTION LONG-TERM INITIATIVE OR HEAL INITIATIVE AND SHE LEADS THE HEAL COMMON DATA INITIATIVE AND Dr. WANDA TREATS PAIN PATIENTS AT THE MILITARY MEDICAL CENTER AND SO PLEASE WELCOME Dr. WANDNER. >> WELCOME TO THE JUNIOR INVESTIGATE POSTER SESSION THERE WILL BE THREE INVESTIGATOR SESSIONS DURING THE NIH SYMPOSIUM AND THE TIMES OF THE OTHER POSTER SESSIONS ARE LISTED HERE ON THE SLIDE. THE JUNIOR INVESTIGATORS WERE SELECTED BY PROGRAM STAFF AND IN ORDER TO QUALIFY AS A JUNIOR INVESTIGATOR, WHO IS ELIGIBLE TO PRESENT OF THIS SYMPOSIUM, ALL OF THE PRE-RECORDED TALKS WILL PLAY ONE AFTER ANOTHER AND THE JUNIOR INVESTIGATORS WILL BE AVAILABLE TO ANSWER QUESTIONS OF THE END OF THE SESSION SO ATTENDEES PLEASE SUBMIT YOUR QUESTIONS OR THE JUNIOR INVESTIGATORS IN THE Q&A BOX AND THE MODERATORS OF THE POSTER SESSIONS WILL REVIEW THE QUESTIONS TO THE JUNIOR INVESTIGATORS. WITH THAT I'M HONORED THE INTRODUCE THE FIRST GROUP OF JUNIOR INVESTIGATORS. THE FIRST SPEAKER IS A POSTDOC TO BAL IRT FELLOW AT THE NATIONAL CENTER OF COM TRAMENT TREE AND INGRAY TIVE HEALTH AND WILL PRESENT ON THE IMPACT OF CRON I OBJECT PAIN CONDITIONS AND AND Dr. TEEN POWELL THE DIRECTOR OF BREAST ON COL TEE AT CANCER CENTER AND WILL PRESENT ON ACUPUNCTURE FOR CHEMOTHERAPY INDUCED NUR ON AGENT' AND Dr. JEFF' BOISSONEAULT FROM THE DEPARTMENT OF CLINICAL AND HEALTH SIGN SIGHEALTHPSYCHOLOGYY DELDINE FROM THE JOINT GRADUATE PROGRAM OF INSTITUTE AND THE NATIONAL CENTER OF COPMENT TREE AND INGRAY TIVE HEALTH AND HE WILL PRESENT ON EVALUATING POTENTIAL DISPARITIES AND SOCIOCULTURAL FACTORS AND ASSESSMENT AND Dr. MINHAUN AT THE NATIONAL INSTITUTE OF DENTAL AND CRANIAL FACIAL RESEARCH AND WILL PRESENT ON VISUALIZATION. WITH THAT, WE'LL GET STARTED WITH THEPRE-RECORDED TALKS. >> I'M A POSTBAC AT THE NCCIH AND I'LL TALK ABOUT MENTAL HEALTH OUTCOMES FOR DIFFERENT CHRONIC PAIN CONDITIONS DURING THE COVID-19 PANDEMIC. SO, AS MANY OF YOU ARE AWARE THE PANDEMIC HAS HAD EXPENSIVE PHYSICAL AND PSYCHOSOCIAL RAMIFICATIONS FOR THE GENERAL PUBLIC AND STUDIES SHOW CHRONIC PAIN PATIENT MAY BE VULNERABLE TO THE IMPACT OF THE COVID-19 PANDEMIC. EXISTING LITERATURE EXAMINING CHRONIC PAIN PATIENTS, SHOW CONFLICTING HEALTH AND PAIN OUTCOMES SUGGESTING THAT THESE OUTCOMES MAY ACTUALLY DEFER BASED ON CHRONIC PAIN CONDITIONS. TO INVESTIGATE THIS WE WOULD DISTRESS, LONELINESS AND ANXIETY DIFFERENTIALLY AND WE ALSO HAVE HYPOTHESIZED HAVE HAVING PAIN CONDITIONS WOULD OUTCOME THESE OUT COMES AND IT WAS 804 CHRONIC PAIN PATIENTS FOCUS ON THE 481 PATIENTS AND WHO ENDORSED ONE WON I CAN PAIN CONDITION ONLY. MENTAL HEALTH OUTCOMES WERE SELECTED OVER A SIX MONTH PERIOD AND PAIN INTENSITY WAS COLLECTED AT THE END OF THE STUDY AND PRIOR MENTAL HEALTH STATUS WAS EVALUATED AT BASELINE. CHRONIC PAIN CONDITIONS WERE CATEGORIZED USING THE CLASSIFICATION OF DISEASE AND BASED ON FREE RESPONSES INCLUDED IN THE CHRONIC PAIN SCALE. MOVING ON TO OUR RESULTS ARE THEY SHOWED MAIN EFFECTS OF CHRONIC PAIN CONDITIONS AND ONLY TWO OUTCOMES ARE SHOWN IN THE FIGURES ON THIS POSTER, SIMILAR TRENDS WERE OBSERVED FOR ALL-OUT COMES. TO KEEP POST HOCKEY ANALYZE REVEALED PARTICIPANTS OF CHRONIC PRIMARY PAIN HAD GREATER LEVELS OF DISTRESS DEPRESSION AND SANITY AND LONELINESS AND THEN THOSE WITH PATHIC PAIN, MUSCULAR SKELETAL PAIN AND VISCERAL PAIN AND THOSE WITH HEADACHE OR ORAL FACIAL PAN HAD GREATER LEVELS OF DISTRESS, LONELINESS THAN THOSE WITH MESS CUE LALL SKELETAL PAIN. WE FOUND THAT PAIN INTENSITY AND A NUMBER OF PAIN CONDITIONS OF ANXIETY AND DISTRESS. IT'S PAIN INTENSITY AND ON THE FAR PLOT SHOWING THE ASSOCIATION BETWEEN THE NUMBER OF PIN CONDITIONS AND MAIN ANXIETY AND HE WILL NOTE HERE, THAT THE MAJORITY OF OUR PARTICIPANTS HAVE EITHER ONE, TWO OR THREE PAIN CONDITIONS WHERE WE SEE THIS TREND. SO THESE PROVIDE A POSSIBLE EXPLANATION FOR THE VARIABILITY WE SEE IN MENTAL HEALTH OUTCOMES IN CHRONIC PAIN ANCIENT DURING N MANAGEMENT MANY TO CONSIDER THE UNIQUE NEEDS AND OUR STUDY HAVE AND OUR MEASURES OF PAIN ALSO ROW LIED ON THE PARTICIPANTS RETROSPECTIVE MEMORY OF PAIN, SO THAT'S ANOTHER LIMITATION. AND FOR FUTURE DIRECTIONS, WE'LL INVESTIGATE HOW DIFFERENT CHRONIC PAIN CONDITIONS INFLUENCE VARIOUS OTHER MENTAL HEALTH AND BEHAVIORAL OUTCOMES AND WE'RE EXCITED TO CONTINUE EXPLORING THESE QUESTIONS. THANK YOU. >> GOOD MORNING, MY NAME IS TIN BELL AND THE TITLE OF OUR PRESENTATION IS ACUPUNCTURE FOR CHEMOTHERAPY INDUCED PERIPHERAL NER ON AGENT' AND IT'S A PAINFUL COMPLICATION OF NEURO TOXIC CHEMOTHERAPY. IT AFFECTS 68% OF CANCER PATIENTS. IT CAN LAST FOR YEARS AND ASSOCIATE IN PAIN AND WORSEN FUNCTION AND QUALITY OF LIFE. CURRENTLY, THERE'S NO GOOD TREATMENT FOR IT AND ACUPUNCTURE IS A WIDELY USED, MINIMUMLY INVASIVE AND SAFE TRADITIONAL CHINESE MEDICINE TECHNIQUE CURRENTLY AVAILABLE FOR PATIENTS IN 75% OF ACADEMIC CANCER CENTERS IN THE U.S. EVEN THOUGH IT HAS BEEN ESTABLISHED AS THE EFFECTIVE TREATMENT FOR REDUCING CHRONIC MUSCULAR SKELETAL PAIN IT'S PATHIC PAIN HAS NOT BEEN ESTABLISHED. SO OUR GRO COMPLED A PILOT SHOWE AMONG SOLID TUMOR PATIENTS WITH MODERATE TO SEVERE CIPN SYMPTOMS. THE PATIENTS WERE RANDOMIZED TO ELECTRO ACUPUNCTURE, SHAM ACUPUNCTURE AND USUAL CARE FOR EIGHT WEEKS AND THEN FOR FOUR WEEKS. SO AS YOU CAN SEE, AT THE END OF WEEK EIGHT, THEY RECEIVED EIGHT WEEKS INTERVENTION AND FOLLOW-UP AT WEEK 12, WEEK 18 AND WEEK 24. THE TRIAL IS ON GOING. THE TARGET IS 250 PATIENTS. RIGHT NOW, WE HAVE 39 PATIENTS. THANKS FOR YOUR INTEREST. >> HI, EVERYONE, I'VE JEFF ASSISTANT PROFESSOR IN THE DEPARTMENT OF CLINICAL AND HEALTH PSYCHOLOGY AT THE UNIVERSITY OF COLOR WHERE "HAVE BEHAVIORAL HEALTH I'M GOING TO TALK TO YOU TODAY ABOUT NEW INSIGHTS INTO MECHANISMS UNDERLINED ALCOHOL ANDAL GEESIA AND WE HAVE COMBINED DATA FROM TWO LABS IN THE CONTEXT OF PAIN ALTHOUGH WE DO UNDERSTAND FROM A LIMITED EXPERIMENTAL LITERATURE ACUTE ALCOHOL INTAKE DOES INCREASE PAIN THRESHOLD AND REDUCE PAIN INTENSITY ACROSS EXPERIMENTAL PAIN INDUCTION MODALITIES IN PEOPLE WITHOUT CHRONIC PAIN, THERE'S NEVER BEEN STUDIES EXAMINING THE ACUTE ANALOGY IN PEOPLE WITH CHRONIC PAIN OR THE EXTENT TO WHICH FACTORS OTHER THAN QUANTITIVE CHANGES AND SENSORY FUNCTION BE FROM PAIN THAT COMES WITH CONSUMING ALCOHOL. WE HAD A TOTAL SAMPLE OF 119 PEOPLE AND FROM TWO STUDIES AND STUDY 2, 21 INDIVIDUALS OR 41% HAD CHRONIC JAW PAIN. WE ASSESSED PAIN THRESHOLD, PAINEN TEES TEE AND PERCEIVED RELIEF USING HEAT PAIN IN STUDY ONE AND PRESSURE AT THE MASS IN STUDY 2 AND WE EXAMINED CENTRAL FACTORS CONTRIBUTING TO PAIN RELIEF USING HIGHER AGGRESSION WHICH WILL BE ON THE NEXT PAGE. AS YOU CAN SEE FROM THE RESULTS, WE DID FIND THAT CONSISTENT WITH THE LITERATURE, ALCOHOL INTAKE SIGNIFICANT INCREASE PAIN THRESHOLD COMPARED TO PLACEBO. THESE WERE LARGE EFFECTS. AND HIGHER AGGRESSION DID INDICATE THAT ALTHOUGH EXPECTED OF ALCOHOL ANALOGY SEE YA AND IT WOULD RELIEF PAIN -- AND PROBLEE NOT SIGNIFICANTLY PREDICTORS. FINALLY, ALTHOUGH WE FOUND THAT ALCOHOL DID SIGNIFICANTLY REDUCE PAIN INTENSITY, ESPECIALLY IN STUDY 2, THESE EFFECTS DID NOT DIFFER BETWEEN INDIVIDUALS WITH AND WITHOUT CHRONIC JAW PAIN ALTHOUGH PEOPLE WITH CHRONIC JAW PAIN DID REPORT MORE PAIN. SO TAKEN TOGETHER, THESE RESULTS SUGGEST THAT ALCOHOL DOES HAVE ANNAL GEESE I CAN EFFECTS IN TAB LORI SETTINGS AND AND THEY HAVE ANALGESIA AND INCLUDING INTOXICATION. THE MEASURES OF PAIN AND THRESHOLD ARE INTENSITY PER SE. >> PAIN ARE RAMPANT AND WOMEN AND BLACK PATIENT EXPERIENCE MORE PAIN, LESS PAIN ASSESSED AND LESS PAIN IS TREATED IN THIS GROUP TOO. THIS LARGE LITERATURE IS ON PURPOSE OF SUPPORT AND HOWEVER THERE HAVE BEEN STUDIES LOOKING AT THE ROLE OF PAIN EXPRESSION AND RESULTS HAVE BEEN QUITE INCONSISTENT AND THAT IS IN PART BECAUSE THERE ARE NO DIVERSE DATA OF PAIN. OUR WORK IS DEVELOPING THOSE. WE BELIEVE PARTICIPANTS RELATE MORE PAIN WITH HIGHER INTENSITY AND WHITE AND MEN TARGETS COMPARED TO BLACK PERSPECTIVELY. WE HAVE PARTICIPANTS WATCH VIDEO OF PAIN SIMULATION AND BASED ON THIS PERSON WAS IN PAIN OR NO PAIN AND THEY VARY HOW INTENSE THAT SENSATION WAS. THEY ANSWERED A FEW QUESTIONS. 49% COMPLETED THIS TASK ON-LINE OVER TELE CAST AND WE USED MODELS AND TO ASSESS PAIN COMPETITION AND INTENSITY. THERE'S A PAIN CATEGORIZATION AND WE SAW A TARGETED PATIENTS BEING PAIN INCREASED THE ODDS OF PAIN AND WE DO NOTE THE OVER ALL PAIN WAS LOW AND ONLY 50% HERE ON THIS GRAPH AND AS IT TARGETS FABLE EXPRESSION TARGET TEE INTEENSED THERE'S A GREATER LIKELIHOOD OF THE PAIN AND WE ALSO BIASES PRESENT SO WE SAW THAT THEY ARE PAIN IN MEN COMPARED TO AS WEL MEN. WE DID SEE MODERATION HERE WITH GREATER RACIAL BIAS ENDORSEMENT IN GROWN LEADING TO GREATER ODDS OF PAIN FOR WHITE TARGETS COMPARED TO BLACK TARGETS 6789 E TRIALERS HERE IN BLUE INCREASED PERCEIVERS INTENSITY RATINGS. WE SAW THERE WAS NO EFFECT ON FACIAL EXPRESSION INTENSITY ON RATINGS AND IT'S INTERESTING TO US AND WE DID SEE BIAS FOR WHITE TARGETS COMPARED TO BLACK TARGETS. WE DIDN'T SEE TARGET GENDER ON PERCEIVED INTENSITY AND ONCE AGAIN, WE DID SEE AN EFFECT OF FOR WHITE COMPARED TO BLACK TARGETS IT WAS A PAIN AND RECEIVER PERCEIVED PAIN WITH A TARGET RATED PAIN GREATER FACIAL EXPRESSIONS AND FOR ANY OTHER INTENSITY AND AND PAIN MORE IN MEN AND AND WE BELIEVE IT'S INCREASED TO OUTCOMES AND ADDRESSING PROVIDING INTERVENTIONS FOR RACIAL BIAS WILL NEED TO DECREASE IN BIASES FOR PAIN ASSESSMENTS. >> I'M FROM NATIONAL INSTITUTE OF DENTAL AND CRAN Y'ALL RESEARCH AND TODAY I WOULD LIKE TO TALK ABOUT REALIZATION OF LABELED HERE WITH 6 TO SIMULTANEOUSLY MONITOR NEURO RESPONSE TO AND NOXIOUS STIMULI INCLUDING MECHANICAL, THERMAL AND ALL KINDS INDUCE DIFFERENT ACTIVITIES TRANCE ANT AND SECOND DEPENDING IS A KEY NEURO INVOLVED IN PAIN SIGNALING AND WE USE TRANS AGAIN WE CONDUCT F IMAGING AND ACTIVITY ANYWAY AND TO THE MICE THE TOTAL INTENSITY INCREASED AS WELL AS THE NUMBER OF AK TA RATE ISED NEURONS AND WE ALSO FIND OUT THAT -- IT INCD COMPARED WITH CONTROL. THE DATA SHOWS INCREASING ACTIVITY SHOWED SIGNIFICANT PAIN PERCEPTIONS. BETTER FACIAL INFORMATION PAIN IN MICE COULD BE ALLEVIATED BY BEHAVIOR TFP5. AS YOU CAN SEE HERE, THE NEURO RISK RESPONDS TO BOTH BRUSH AND WITH WHITE IF SIGNIFICANTLY DOUGH CREASED AFTER A APPLICATION OF 5 AND SPECIFICALLY DECREASED A TOTAL COST OF INTENSITY IN RESPONSE FOR STIMULI SO THE INHIBIT INHIR INHIBITS AK TAIZATION OF SENSORY NEURONS AND IT DEMONSTRATES WITH A PATH WAY TO THERAPEUTICS. THE ACTIVITY AT PARAMETER SENSORY NEURONS COULD OFFER BETTER AND SAFER TREATMENT FOR FACIAL PAIN. THANK YOU FOR YOUR ATTENTION. >> THANK YOU FOR YOUR TALKS. I'LL ASK YOU TO TURN ON YOUR CAMERAS AND ATTENDEES FEEL FREE TO SUBMIT QUESTIONS AND FOR THE ATTENDEES TO ANSWER IN THE Q&A SESSION AND YOU WILL GET STARTED WITH SOME OF THE INITIAL QUESTIONS THAT HAVE BEEN SUBMITTED ALREADY. SO THE FIRST QUESTION IS TO MYA, ANY HYPOTISIESE WHY PRIMARY CHRONIC PAIN HAS WORSE MENTAL HEALTH OUTCOMES COMPARED TO OTHER CHRONIC PAIN CONDITIONS? >> YES, SO, ACTUALLY ONE OF THE PAIN CONTINUES THAT IS CATEGORIZED IN CHRONIC PRIMARY PAIN IS FIBER HIGH GAL AND AS MANY OF YOU NOW THE IDEOLOGY IS UNKNOWN AND THERE'S NO LESION, OR BLOOD WORK OR ANYTHING THAT CAN BE DONE THAT COMES BACK AND SAYS THIS IS FIBER MYALGIA AND SO WE HYPOTHESIZE THAT SENSE OF UNCERTAINTY AS WELL AS THE LACK OF CONCRETE PLANNER AND TREATMENT AROUND FIBER MYALGIA MAY LEED TO ANXIETY AND DEPRESSION AS OPPOSE TODAY SOME OF THE OTHER CHRONIC CONDITIONS. AND WE DID PREVIOUSLY RUN SOME OTHER ANALYSIS USING A BROADER CATEGORIZATION WHERE FIBER MYALGIA WAS ITS OWN CATEGORY AND WE DID SEE A DRASTIC DIFFERENCE FOR THAT AS WELL. >> GREAT THANK YOU SO MUCH FOR THAT ANSWER. I REALLY APPRECIATE IT. THE NEXT QUESTION IS FOR YOU, ARE CITATIONS OR WESTBOUND LINKS AVAILABLE FOR YOUR WORK THAT YOU CAN SHARE TODAY? >> YEAH, I THINK THAT IT'S ACTUALLY ON THE FIRST SLIDE. SO, THE PILOT DATA WAS PUBLISHED AT THE NETWORK AND I THINK IT WAS LAST YEAR OR 2021 AND THAT IS BASICALLY SUMMARIZING THE RESULTS. WE NOTICED THE ELECTRO ACUPUNCTURE WAS BETTER THAN SHAM ACUPUNCTURE IN TERMS OF REDUCING PAIN BUT IN TERMS OF TINGLING NUMBNESS, THEY ARE BOTH BETTER WITH THE USUALLY CARE OF ACTUALLY REAL ACUPUNCTURE IS NOT THAT MUCH BETTER THAN SHAM ACUPUNCTURE THAT'S WHY IT'S CIP AND PAIN. >> GREAT. THANK YOU, THAT'S SO INTERESTING, REALLY APPRECIATE IT. >> JEFF, THE NEXT QUESTION IS FOR YOU. THE QUESTIONS IS VERY INTERESTING TALK AND THEY'RE NOT SOCIOCULTURAL EFFECTS, ARE THERE CURRENT EXPERIMENTAL MODEL TO SIMULATE THE POTENTIAL SOCIAL EFFECTS, TO REPLICATE LIKELY SOCIAL SETTING FOR MANY DRINKING IN REAL SETTINGS. >> THAT'S A GOOD QUESTION, THERE ARE NOT STUDIES OF ALCOHOL ANALGESIA IN THE CONTEXT OF SOCIAL INTERACTIONS. THERE ARE STUDIES OF SOCIAL EFFECTS OF DRINKING AND DIE ADDS AND GROUPS IN LABORATORY SETTINGS AND IN NATURALISTIC SETTINGS AS WELL. I HAVE NOT SEEN THEM COMBINED WITH PAIN IN THAT WAY. IT'S A REALLY INTERESTING THING TO PURSUE MOVING FORWARD. >> GREAT. THANK YOU FOR ANSWERING THAT QUESTION. WE APPRECIATE IT. >> Dr. DILDINE. BASED ON YOUR RESULT, DO YOU HAVE ANY RECOMMENDATIONS ON THE TYPES OF INTERVENTIONS NEEDED TO REDUCE BIASES WITHIN THE PAIN MANAGEMENT FIELD? >> THAT IS A BIG QUESTION. [LAUGHTER] >> IT'S A VERY BIG QUESTION. >> I THINK ULTIMATELY I THINK THERE'S BEEN A LOT OF GOOD DONE IN RECENT YEARS AND THE FIRST STEP IS AWARENESS ON THE PROVIDER END BUT THERE ARE POTENTIAL BIASES IN ASSESSMENTS. NOT JUST RACIAL AND GENDER BUT ALSO ACROSS ALL POPULATION AND UNDER ASSESSING PAIN. SO IT'S A BIG ONE TO CONSIDER. AND I THINK BEYOND IT, THERE'S BEEN SOME INITIAL WORKS SEEING SOME BENEFITS AND PAINING THAT CAN BE OFFICIAL IN TRAINING MEDICAL WRITERS TO EMPHASIS AND BE ABLE TO BETTER ASSESS THE THEME AND SOMETHING THAT WE'RE INTERESTED IN TRYING TO RUN THAT CAN PROVIDE INTERVENTIONS WITH FEEDBACK HELPING DOCTORS UNDERSTAND HOW MUCH WE NEED SOMEONE IN IF THAT WOULD IMPROVE THEIR ABILITY TO SEE PAIN AND THEN OBVIOUSLY WE SAW MODERATION IN OUR TASK WITH RACIAL BIAS AND THAT MAKING THOSE OUTCOMES WORSE. AND THAT CAN GET INTO SOME CONTROVERSIAL TOPICS IN TERMS OF WHAT IS THE BEST WAY TO DEAL WITH THAT OBVIOUSLY, LOTS OF ORGANIZATIONS HAVE TRIED TO DO TRAININGS ON IMPLICIT BIAS AND ALL OF THOSE THINGS AND I THINK THEY'VE HAD KIND OF MINIMAL POSITIVE OUTCOMES AT THIS POINT SO I NEED RECOGNITION OF BIAS IMPLICIT ON THEIR OWN AREN'T MAKING THAT MUCH OF A DIFFERENCE IN TERMS OF WORKFORCE CHANGE SO THERE'S NO LOT FOR US TO CONSIDER AND THERE'S A LOT TO BE DONE IN THE FIELD AND BEYOND THIS PAIN AND HEALTH AND HOW TO MAKE INTERVENTIONS THAT ARE ACTUALLY LONG LASTING AND CHANGE BEHAVIORAL OUTCOMES. >> IT'S SUCH AN IMPORTANT TOPIC AND I'M GLAD TO SEE THAT YOU ARE WORKING ON IT. NEXT QUESTION, IS FOR Dr. HU. DO THEY REGULATE ALL TIMES OF PAIN, MECHANICAL, CHEMICAL AND THERMAL OR ONLY CERTAIN TYPES OF PAIN? >> SO, THAT'S A GOOD QUESTION, THANK YOU. SO, IN MY EXPERIMENT I TRIED ALL DIFFERENT KINDS OF STIMULATIONS INCLUDING MECHANICAL, YEAH, AND ALSO I TRIED HAIR STIMULATION AND WHICH LIKE I ALSO CALL IT AS PINCH SO REGULATED,. I'D LIKE TO WELCOME YOU BACK, AGAIN. YOU STILL HAVE ANOTHER VERY INTERESTING PANEL, WHICH FOCUSES ON THE INTEGRATION OF WHOLE-PERSON TOOLS AND APPROACHES. AND I'D LIKE TO INTRODUCE Dr. LIN. A PROGRAM DIRECTOR IN THE INTRA GRAY TIVE NEUROSCIENCE BRANCH WHERE HE MANAGED A PORTFOLIO ON CLINICAL AND TRANCATIONAL RESEARCH IN THE AREAS OF PAIN AND HIV/AIDS. THIS PARTICULAR AREA OF FOCUS ARE ON CHRONIC PAIN AND -- ON THE INTERACTIVE OF ADDICTIVE DRUGS ON COGNITIVE FUNCTIONING PATIENTS OF HIV/AIDS AND HE WAS AN ANESTHESIOLOGIST AND A PHYSICIAN SCIENTIST AND ENTA GRAY TIVE HEALTH SO PLEASE WELCOME Dr. LIN. >> >> HI, EVERYONE, GOOD AFTERNOON. IT'S MY PLEASURE TO TEAM UP WITH EXCELLENT INVESTIGATORS TO CARRY OUT THIS PANEL AND THIS DECISION WAS STARTED BY Dr. MARK PAIN RESEARCH TO INTRODUCE AND FOLLOWED BY Dr. LAUREN ATTARS A PROCESAROUSAL OF THE FRONTAL X AND THEN Dr. DANIEL BAUER WILL TELL A PERSON ORIENTED APPROACH AND ASSESSING CHRONIC CONDITIONS WITH INDIVIDUALS DELIVERED BY DAVID WILLIAMS. Dr. MARK JASON IS A PROFESSOR OF THE UNIVERSITY OF WASHINGTON. HE IS THE CURRENT EDITOR-IN-CHIEF FOR THE JOURNAL OF PAIN WHO HAS EFFECT AND MECHANISM FOR PAIN INTERVENTIONS AND HE PUBLISHED OVER 600 ARTICLES IN PEER REVIEW JOURNALISTS AND HIS CO-AUTHOR OF OVER 40 BOOKS AND CHAPTERS AND HAS ADDED BOOKS WITH THAT, Dr. JANSSEN. >> ARE THE SLIDES GOING TO BE UP THERE THEY GO. I'LL TALK AS Dr. ELLEN SAID ABOUT THINKING OF PAIN RESEARCH FROM THE WHOLE PERSON PERSPECTIVE NEXT SLIDE, PLEASE. AND I'M GOING TO TALK BRIEFLY ABOUT THE STRENGTH AND WEAKNESSES OF TRADITIONAL APPROACHES TO STUDYING PAIN TREATMENTS AND FOCUS ON LOOKING ABOUT, TALKING ABOUT ALTERNATIVE APPROACHES THAT ARE MORE PERSON ORIENTED AND THE CENTRAL IDEA IS THAT I'M THINKING THESE NEW APPROACHES MIGHT BE MOST USEFUL TO US FOR HELPING PEOPLE WITH PAIN. AND SO OF COURSE, THE TRADITIONAL EXPLANATORY TRIAL ARE TO TEST THE EFFICACY OF A PARTICULAR TREATMENT AND TO DO THAT WE DESIGN STUDIES THAT CONTROL FOR THE VARIABLES EXCEPT FOR THE TREATMENT CONDITION. WE WANT TO REALLY MINIMIZE PARTICIPANT HETEROGENEITY AND LOOK AT SUBGROUPS OF PATIENTS AND STANDARDIZE THE TREATMENTS TO MAKE SURE THAT THEY'RE ALL SIMILAR DONE IN THE SAME WAY AND INCLUDE CONTROLLED CONDITIONS THAT CONTROL FOR EVERYTHING GIVEN IN THE ACTIVE TREATMENT WE WANT TO TEST FOR WHAT WE THINK IS THE ACTIVE COMPONENT, NEXT SLIDE, PLEASE. AND VERY STRONG APPROACH IT MAXIMIZES POWER AND ALSO WE ALMOST ALWAYS HAVE THIS ONE OUTCOME VARIABLE BECAUSE WE WANT TO MAXIMIZE AND WE JUST DO ONE TEST, IS THIS STUDY TREATMENT EFFECTIVE OR NOT? NEXT SLIDE, PLEASE. AND SO THIS APPROACH WE CAN DRAW VERY FIRM CONCLUSIONS WHEN IT'S DESIGNED REGARDING WHETHER OR NOT THE TREATMENT IS EFFECTIVE. AND THIS FOCUSES ON THE TREATMENT. AND SO IT'S A HIGHLY STANDARDIZED TREATMENT USUALLY IN THE STUT STUDIES. IT'S NOT PROVIDED IN THE REAL WORLD AND THE FOCUS IS ON THE TREATMENT NOT THE PERSON OR EVEN THE WHOLE PERSON. NOT EVEN A PART OF THE PERSON, IT'S ABOUT TREATMENT. NEXT SLIDE, PLEASE. AND IT ONLY LOOKS AT THE EFFECTS FOR A HIGHLY SELECTED GROUP THAT ARE NOT THE NORM SO NEXT SLIDE, PLEASE. AND SO, IN GENERAL, ALSO THE EFFECTS TEND TO BE MODEST AT BEST SO WE DON'T SEE OFTEN THESE HUGE GROUND-BREAKING THESE ARE POPULAR FOR GOOD REASON. THEY ALLOW FOR TESTING OR INTERVENTIONS IN REAL WORLD CONDITIONS AND THEY ALLOW FOR GREATER HETEROGENEITY IN THE STUDY SAMPLE WHICH IS THE PATIENTS THAT WE ACTUALLY SEE AND IT ALSO GREATER HETEROGENEITY IN THE TREATMENT AS DELIVERED WHICH IS HOW TREATMENTS ARE DELIVERED. NEXT SLIDE, PLEASE. AGAIN, THIS FAVORS EXTERNAL DATA THAT WE CAN DRAW CONCLUSION 0 THESE TRIALS REGARDING TREATMENT EFFECTS AS THAT YOU ARE PROVIDED. NEXT SLIDE, PLEASE, THE FOCUS IS STILL ON THE TREATMENT AND NOT THE PERSON. AND AGAIN, THE EFFECTS TEND TO BE EVEN MORE MODEST WHEN YOU ADD THE NOISE OF A PRAGMATIC TRIAL SO MY OWN BELIEVE IS WE DON'T HAVE THE RESOURCES TO DESIGN SUCH STUDIES FOR EVERY TREATMENT WE WANT TO EXAM AND THEY MAY NOT BE THE MOST EFFICIENT WAY FOR US TO UNDERSTAND HOW TO DELIVER TO PEOPLE SO THAT REDUCE OUR SUFFERING AND A DIFFERENT APPROACH IS TO EMBRACE VARIABILITY RATHER THAN LIMIT IT AND MEASURE THAT VARIABILITY AND CONDUCT ANALYSIS TO UNDERSTAND HOW THAT VARIABILITY IS RELATE TODAY OUR OUTCOMES TO UNDERSTAND TWO THINGS, WHY THE TREATMENT WORKS AND FOR WHOM IT WORKS. AND THIS SHIFTS THE FOCUS REALLY TO THE PERSON. NEXT SLIDE, PLEASE. AND SO THREE EXAMPLES OF THESE APPROACHES I WANT TO INTRODUCE ARE THE MEDIATION, MODERATION AND MODERATED MEDIATION APPROACHES. NEXT SLIDE, PLEASE. AND IT MEDIATION ANALYSIS, NEXT SLIDE, PLEASE, WE CAN ON AND A ASSIGN AND WE CAN LOOK AT THE EFFECTS OF THAT ON AN OUTCOME. THIS IS A CLASSIC EXPLANATORY TRIAL AND EFFICIENCY TRIAL. NEXT SLIDE, PLEASE. BUT WE CAN ALSO MEASURE AS PART OF THAT, POTENTIAL MECHANISM VARIABLES WE THINK THAT WILL PLAIN HOW AND WHY THE TREATMENT WORKS AND WE CAN COMPUTE THE EFFECTS OF THE TREATMENT ON THAT MECHANISM AND THEN STUDY HOW CHANGES IN THAT MECHANISM EFFECT OUTCOME AND THE CO EFFICIENT THERE. IT'S STRONG BECAUSE WE'RE ABLE TO DRAW CONCLUSIONS ABOUT THE TREATMENT ON THE MECHANISM VARIABLE, NEXT SLIDE, PLEASE. WE CAN UNDERSTAND THE EXTENT TO WIT MECHANISM VARIABLE EXPLAINS OUTCOMES AND IT CAN SUPPORT THIS ANALYSIS IS NOT CAUSAL BUT IT CAN HELP RULE OUT POTENTIAL MECHANISMS THAT WE THINK ARE VARIABLE AND YOU CUT AWAY FROM WOOD ALL THE PIECES THAT AREN'T A GUITAR AND WHAT IS LEFT, THE MECHANISMS THAT ARE MOST LIKELY PLAYING A ROLE AND WE CAN STUDY MANY VARIABLE AND WE CAN STUT' THE WHOLE PERSON BIOLOGICAL VARIABLE, SOCIAL VARIABLE, ENVIRONMENTAL VARIABLE AND WE CAN UNDERSTAND ALL THE MECHANISMS TA CAN PLAY A ROLE HERE. NEXT SLIDE, PLEASE. SO AGAIN, THIS IS UNDERSTANDING WHY THE TREATMENT WORKS AND IT'S NOT ABOUT IF IT DOESN'T WORK BUT WHY. AND ANOTHER APPROACH IS A MODERATION ANALYSIS. AND THIS CASE AGAIN WE CAN DESIGN A STUDY COULD CAM PAIR TWO TREATMENTS AS A PRAGMATIC TRIAL WE PRESSURE A PERSON VARIABLES TO UNDERSTAND WHAT IT IS ABOUT THE PERSON THAT INTERACTS WITH THIS OUTCOMES AND TO EXPLAIN HOW, FOR WHOM THE TREATMENT WORKS. BECAUSE WE MEASURE THE PERSON VARIABLES THEY HAPPEN BEFORE THE TREATMENT IS GIVEN WE GET PRECEDENT SO IT'S A PREDICTIVE ANALYSIS. NEXT SLIDE, PLEASE. SO YOU CAN ALSO LIKE WITH MEDIATION CAN STUDY A WHOLE VARIETY OF VARIABLES AND IT'S BEST TO STUDY WHEN THEY'RE THEORETICALLY RELATED AND WE HAVE A THEORY TO EXPLAIN AND TEST ABOUT WHY THEY MIGHT BE MODERATORS. AND AGAIN TO UNDERSTAND FOR WHOM TREATMENT WORKS AND AGAIN THE FOCUS IS ON THE PERSON AND HOW THAT PERSON INTERACTS WITH TREATMENT. AND THEN I WANT TO TALK ABOUT MODERATED MEDIATION AND IN THIS CASE, THEY HAVE SIMILAR WAYS OF A VARIETY OF MEDIATORS. BUT THEN LOOK AT WHAT IT IS ABOUT THE PERSON THAT MIGHT EXPLAIN HOW THESE DIFFERENT TREATMENTS WORK. SO AN POXEL OF A EXAMPLE OF EES WHO MIGHT SPEND BEST TO WHAT TREATMENT AND PREDICTS THE PARTICULAR MEDIATORS AND IT'S A HIP NOD I CAN TO PAIN OUTREACH AND IT'S TO UNDERSTAND IN THIS CASE THE PERSON FACTORS THAT IMPACT THE EXPLANATORY VARIABLES, DIFFERENT PEOPLE MIGHT RESPOND TO DIFFERENT TREATMENTS FOR DIFFERENT REASONS AND THIS ANALYSIS ALLOWS FOR THAT. THE PRIMARY CONCERN RAISED BY REVIEWERS OF GRANTS AND EDITORS OF JOURNALS, IS THAT WHEN YOU EXAMINE ALL OF THESE PERSON VARIABLES, YOU ARE FINDING ONES THAT ARE SIGNIFICANT BUT THAT AREN'T IN FACT SIGNIFICANT IN POPULATION. SO, TO ADDRESS THIS FOUR REVIEWERS AND EDITORS OF GRANTS AND EDITORS OF ARTICLES, I USUALLY SELECT JUST ONE OR A SMALL SUBSET OF PRIMARY VARIABLES TO LOOK AT AND MAKE HYPOTHESIS ABOUT THAT AND MAKE THE OTHERS EXPLANATORY SECONDARY BUT MY VIEW IS THAT WE ARE TOO DEPENDING ON THE P-VALUE THAT IS, WE DON'T THINK WE SHOULD USE ONE STUDY TO TEST ONE QUESTION USING ALL THE POWER BUT RATHER TO USE OUR RESEARCH TO UNDERSTAND EFFECT SIZES AND LOOK AT MULTIPLE STUDIES OVER TIME TO SEE WHAT THE TRUE EFFECT SIZES ARE ON AVERAGE SO, I'M HOPING THAT AS A FIELD WE'LL MOVE FROM GOALS OF EXAMINING THE RELIABILITY OF THE SINGLE EFFECT PROVIDING RELIABLE ESTIMATES OF MANY EFFECTS, THE WHOLE PERSON. NEXT SLIDE, PLEASE. I THINK WE'VE BEEN USING RIGOROUSLY DESIGNED EXPLANATORY TRIALS FOR DECADES AND THEY'RE VERY STRONG TO DEFINITIVELY ANSWER ONE QUESTION -- DOES THE TREATMENT WORK? BUT, I HAVE A CONCERN THAT THE FONDINGS MAY BE OF LIMITED PRACTICAL USE BECAUSE I THINK WE CAN CONSIDER PUTTING THE WHOLE PERSON BACK INTO OUR CLINICAL RESEARCH AND ALLOWING GREATER VARIABILITY AND EMBRACE VARIABILITY LIKE THERE IS IN THE REAL WORLD AND RIGOROUSLY MEASURE THAT VARIABILITY AND ASSESS KEY BIOLOGICAL FACTORS AND AT BASELINE TREATMENT OF POST TREATMENT AND THEN CONDUCT ANALYSIS TO UNDERSTAND THE VARIABLE THAT'S EXPLAIN WHY TREATMENTS WORK AND FOR WHOM THEY WORK. AND, CONSIDER MODERATED MEDIATION TO UNDERSTAND FOR WHOM DIFFERENT MEDIATORS PLAY A ROLE. AND THAT IS IT. THANK YOU VERY MUCH. I'M LOOKING FORWARD TO HEARING Dr. ATLAS' TALK ABOUT VENTROMEDIAL PREFRONTAL CORTEX BECAUSE WE ARE STUDYING INTERIOR ACTIVITY IN THE LEFT ANTERIOR BECAUSE WE'RE FINDING A LOT OF ACTIVITY THERE IS GOOD IF YOU WANT TO BE COGNITIVE THERAPY BUT CAN GET IN THE WAY OF HYPNOSIS SO WE'RE TRYING TO UNDERSTAND THIS FOR PRECISION MEDICINE SO I'M LOOKING FORWARD TO HEARING Dr. ATLAS, THANK YOU, VERY MUCH. >> THANK YOU VERY MUCH. THANK YOU FOR THAT SET UP WITH MEDIATION ANALYSIS BECAUSE I ACTUALLY HAVE MODERATED MEDIATION IN THIS TALK. SO, I AM A TEN YOUR TRACK INVESTIGATORS WITH AFFECT OF NEUROSCIENCE IN PAIN IN THE NATIONAL CENTER FOR COMMENT TREE ENTA GRAY TIVE HEALTH AND OUR LAB IS INTERESTED IN MECHANISMS OF HOW EXPECTATIONS SHAPE PAIN. WE USED AS A GUIDED MODEL IN ORDER TO UNDERSTAND HOW THE PSYCHOSOCIAL CONTEXT SURROUNDING TREATMENT INFLUENCES CLINICAL OUTCOMES AND BECAUSE PLACEBO EFFECTS ARE LARGEST IN PAIN AND SA DETECTIVE OUTCOMES THIS IS A REALLY MOTIVATING FACTOR FOR WHY WE SHOULD STUDY PLACEBO TO UNDERSTAND HOW PSYCHOLOGICAL FACTORS CAN DIRECTLY AFFECT PATIENT OUTCOMES. SO, OUR APPROACH IS TO USE BASIC SCIENCE TO ISOLATE COMPONENT MECHANISMS AND DO CLINICAL EXTENSIONS AND WE CAN TEST WHETHER THEY'RE ALTERED IN PATIENT POPULATION AND OUR GOAL IS TO INTEGRATE THESE PSYCHOLOGICAL FACTORS ALONGSIDE TREATMENT TO MAXIMIZE PATIENT OUTCOMES. NEXT SLIDE. SO OUR APPROACH YOU CAN CLICK THROW TIMES. IS BASICALLY TO MANIPULATE THE STIMULUS INTENSITY, PSYCHOLOGICAL FACTORS ASK CONTEXT SURROUNDING TREATMENT TO MEASURE A WHOLE HOST OF DIFFERENT PARALLEL MEASURES RELATED TO PAIN INCLUDING REPORTS ON RESPONSES AND MEDIATORS AND TO UNDERSTAND HOW THESE RESPONSES ARE MODERATED BY THINGS LIKE PATIENT DYING KNOW PAY DIAGNOSIS, TODAYI'LL TALK AE OF THIS WHOLE-PERSON HEALTH, I'LL TALK ABOUT THE RELATIONSHIP BETWEENDEDUCK TIVE PAIN HOW IT S PAIN EXPECTANCY AND AROUSAL. PAIN IS AN UNPLEASANT SENSORY AND EMOTIONAL EXPERIENCE WITH TISSUE DAMAGE AND IT IS DISTINCT FROM THOSE THE NEURAL PROCESS OF ENCODING STIMULI. PAIN CAN GO FURTHER DIVIDED INTO IT'S SENSORY OR DIS CRIMINAL NA TIVE COMPONENT AND IT OF COURSE TIVE IN MOTIVATIONAL, PAIN UNPLEASANT. SO, BASICALLY, WITH THIS DISTINCTION, THE IDEA IS IF WE CAN UNDERSTAND HOW PSYCHOLOGICAL FACTORS WERE ALONG THIS PATHWAY WITH NO SUSPENSION TO PAIN DO THEY HAVE THEIR IMPACT. AND WE'VE IDENTIFIED GRADIENTS ALONG THE CINGULAR LET RELATED TO NO SUN EXCEPTION TO PAIN OR THAT FORMALLY MEDIATE THE LINK BETWEEN PAIN. SO, MY POSTDOC WAS INTERESTED IN TESTING WHETHER AUTO NOM I CAN ACTIVITY IS MORE RELATED TO NO SUN ACCEPTION THAN PAIN AND HOW PAIN SPEEXPERIENCE TO PAIN. SO, DON DEVELOPED A TWO-STEP PAIN ASSESSMENT TASK WHERE INDIVIDUALS CAME INTO THE LAB AND EXPERIENCED ACUTE PAIN WITH A THERMO DEVICE ON THE LEFT WHICH HEATS UP TO DIFFERENT TEMPERATURES. AND EVERYBODY RECEIVED A WHOLE DIFFERENT RANGE OF TEMPERATURES ON EACH TRIAL THEY WOULD TELL US IF IT WAS PAINFUL OR NOT, CLICK. AND THEN HOW PAINFUL IT WAS. OR HOW INTENSE IT WAS IF IT WASN'T PAINFUL. IN IN ADDITION WE MEASURED STAYING CONNECTED AS WELL AS PUPIL DILATION. WHAT WE FOUND IS THAT WHAT WE SEE WHEN INDIVIDUALS AND ON THE WHY EXAMINATION IS AND THE HEAT AND IT COMES ON SLOWLY AND IT'S AT MAXIMUM AND YOU CAN SEE THERE'S AN EFFECT OF TEMPERATURES ON A TRIAL WHICH SUBJECTS CALLED IT NOT PAINFUL WHEN PEOPLE CALL THOSE TEMPERATURES PAINFUL. AND WHAT WE FOUND IS EVIDENCE OF MODERATED MEDIATION WHERE WHAT WE CAN SEE IS ON THE TRIALS ONE SUBJECT IS CALLED THE TEMPERATURE NOT PAINFUL AND THEN IT DROVE THE SKIN CONDITION AND ON THE TRIALS WHEN INDIVIDUALS CALLED IT PAINFUL, WE FOUND THAT IT AFFECTS THE TEMPERATURE ON SKIN WERE FULLY MEDIATED BY THE SUBJECTIVE PAIN READING SO REALLY WHEN IT'S PAINFUL, IT'S HOW PAINFUL IT IS THAT IS DRIVING YOUR BODY'S RESPONSE WHEREAS IF YOU CHARACTER EYES IT AS NOT PAINFUL IT'S JUST THE INPUT THAT MATTERS. YOU CAN CLICK THIS THREE TIMES. WHAT WE FIND IS THAT THE NERVOUS SYSTEM RESPONSES TO NOXIOUS STIMULI ARE MEDIATED BY EXPERIENCED PAIN AND I SWEAR THAT Dr. JENSON AND I DID NOT HAVE A SET UP YOU WOULD TEACH YOU UP THE BACKGROUND ABOUT THIS. WE REPLICATED THIS IN A SEPARATE PAIN ASSESSMENT TEST AS WELL AS THE PUPIL DILATION AND IT SHOWS LABELING THE STIMULUS AS PAINFUL, SHAPES HOW YOUR BODY RESPONDS TO IT. AS A PSYCHOLOGIST, THIS IS ACTUALLY NOT TOO SURPRISING. THIS IS CONSISTENT WITH THE APPRAISAL THEORY OF MOTION AND THE IDEA HOW WE APPRAISE EVENTS IN THE ENVIRONMENT CAN SHAPE HOW OUR BODY RESPONDS TO THEM. NOW AM I ALLOWED THIS MOVING FORWARD TO LOOK AT THIS KIND OF DECISION THAT IS MAKING PROCESS SURROUNDING PAIN AND TO UNDERSTAND HOW THIS CAN DRIVE OUR BODY'S RESPONSES. IT'S REALLY THE CORNER STONE OF WHAT IS CALLED THIS MARKET AND HYPOTHESIS THAT WAS INTRODUCED IN 1994 AND IT'S THOUGHT THAT THE VMPSC AND THE AND IN ORANGE IS CRITICAL LINKING EMOTION AROUND AROUSAL AND DECISION-MAKING IT COMES FROM BILATERAL LESIONS AND PREFRONTAL CORTEX WHERE THEY FIND, YOU CAN CLICK, THAT INDIVIDUALS WITH LESIONS AND SHOW DEFICITS IN DECISION-MAKING AND IN SHOW BLUNTING THE SKIN CONDUCTANTS WHERE THEY MAKE DIFFERENT DECISIONS ABOUT TRYING TO FIGURE OUT WHAT IS THE OPTIMAL DECK. AND SO BASICALLY, THEY DON'T SHOW SCR IN RESPONSE TO A POTENTIALLY ADVANTAGEOUS DECK AND IT'S THOUGHT THAT IN TURN EXPLAINS WHY THEY SHOW LESS OPTIMAL BEHAVIOR ON THIS TASK. SO THE IDEA IS THAT THE VENTURE PREFRONTAL CORTEX ACTS AS A REPOSITORY BETWEEN REGULATORY STATES SO ON THE LEFT, BASICALLY, IS A LOOP WHERE THE VMPFC GETS IMPACT THROUGH THE BODY AS WE GO THROUGH EMOTIONAL EXPERIENCE AND ON THE RIGHT IT'S OVER TIME, THE VMPSD CAN USE THAT LEARNING TO GUIDE FUTURE DECISIONS. SO OUR HYPOTHESIS, BEGIN THIS LINK BETWEEN AUTO NOM I CAN RESPONSES AND PAIN IS THAT INDIVIDUALS WITH VMPS LESIONS WILL SHOW ALTERED PAIN ACTIVITY HOWEVER IT'S NOT THAT SIMPLE, CLICK. IT'S ALSO KNOWN TO BE A HUB FOR EXPECTATIONS, VALUE AND EFFECTIVE MEANING. SO OVER THE PAST 25 YEARS OR SO THERE'S BEEN SO MANY DIFFERENT REVIEWS ON THE ROLE OF THE OSD BUT THEY ALL CONVERGE ON THE IDEA OF THIS REGISTER ON IS CRITICAL FOR PREDICTION AND GENERATING RULES FROM EXPERIENCE. AND AS I MENTIONED EARLIER AND WE HEARD EARLIER TODAY, EXPECTATIONS DIRECTLY AFFECT PAIN IN THE FORM OF PLACEBO EFFECTS. SO THE IDEA IS, BY LEARNING FROM INTERACTIONS OF PHYSICIAN, THE CLINICAL CONTEXT, OUTCOMES, WE DEVELOP EXPECTATIONS WHICH CAN SHAPE OUR BODIES' RESPONSES AND WE SHOWED THAT RESPONSES TO PAIN PREDICTIVE ISSUES AND THE TRY EIGHT UM PREDICTS RESPONSES IN PAIN PROCESSING MEDIATORS THAT IN TURN DRIVES SUBJECTIVE PAIN. OUR SECOND HYPOTHESIS, THE LESIONS WOULD REDUCE THE IMPACT OF EXPECTATIONS ON PAIN. AND FINALLY, MORE BROADLY, THERE'S ALSO A POSSIBILITY THAT THE MPSD MIGHT IMPACT PAIN ON PLEASANTNESS IN GENERAL SO IT'S BEEN KNOWN FOR A LONG TIME, IT CAN ALTER PAIN ON PLEASANTNESS IN TERMS OF PAIN EFFECT AND STUDIES OF NEUROIMAGING SHOW THAT PAIN RELIEF, WHICH IS -- WE COLLABORATED TO MEASURE THE EFFECTS OF VMPS LESIONS ON PAIN MODULATION. WE MEASURED RESPONSES IN FIVE PATIENTS WITH BILATERAL NEWER SURGICAL LESIONS AS A RESULT SO THEY HAD TISSUE REMOVED SO WE KNOW THAT IT'S BILATERAL AND CAN FIND TWO PREFRONTAL CORTEX AND NO OTHER REGIONS THAT ARE EFFECTS THE PAIN. AND WE COMPARED THEM TO 20 HEALTHY INDIVIDUALS AND EVERYBODY WENT THROUGH THIS ADAPTIVE STAIRCASE CALIBRATION TASK THAT I WON'T DESCRIBE IN DETAIL BUT BASICALLY THROUGH AN ITERATIVE TASK SIMILAR TO EARLIER, WE CAN FIND EACH INDIVIDUAL'S PAIN SENSITIVITY AND THE TEMPERATURES THAT HAVE ASSOCIATED PAIN THRESHOLD AND TOLERANCE. AND WE HAD PEOPLE RATE PAIN INTENSITY BUT ALSO UNPLEASANTNESS BECAUSE OF THIS HYPOTHESIS AND HERE IS AN EXAMPLE INDIVIDUAL IN THE LESION GROUP, CLICK. WE FOUND THAT VMPS LEGION DID NOT IMPACT PAIN SENSITIVITY OR UNPLEASANTNESS SO YOU CAN SEE ON THE Y AXIS IS INTENSITY OR PAIN AND UNPLEASANTNESS AND ON THE X AXIS IS TEMPERATURE AND THE PATIENTS' IN BLUE SHOW VERY SIMILAR RESPONSES TO THE HEALTHY CONTROLS. SO, YOU CAN SKIP THIS. SO TO TEST OUR FIRST HYPOTHESIS WE FOUND THAT IN FACT THERE WAS NO IMPACT OF THE LESIONS ON OVER ALL PAIN SENSITIVITY. AND OUR NEXT TEST WAS WHETHER THE VMPFC HAS EFFECTED ON PAIN. AND BASICALLY WHAT WE DID IS WE HAD INDIVIDUALS UNDERGO A A TASK IN WHICH THEY WERE INSTRUCTED THEY WOULD PREDICT LOWER HIGH P AND THEY WENT THROUGH CONDITIONING WHERE IT WAS REINFORCED WITH A LOWER TEMPERATURE AND HIGH TEMPERATURE AND DURING A TEST PHASE, INDIVIDUALS RECEIVED SIM YOU LIE CALIBRATED TO MODERATE PAIN. AND WHAT WE'VE SHOWN ACROSS MANY DIFFERENT PAPERS IS THAT WHEN THE SAME MEDIUM TEMPERATURES IS PROCEEDED BY LOW PAIN CUES IN YELLOW RELATIVE TO HIGH PAIN CUES IN RED, INDIVIDUALS REPORT LESS PAIN AND CLICK. SO WE MEASURED BOTH PAIN RATINGS AND AUTO NOM I CAN RESPONSES IN RESPONSE TO NEED MEDIUM TEMPERATURE STIMULI AND SO WE CAN CLICK AGAIN. AND THESE WERE SUSTAINED AND GREW OVER TIME AND SO BASICALLY, INDIVIDUALS WITH VMPS LESIONS EXPECTED MORE PAIN WITH A PIE PAIN CUE AND THEN INDIVIDUALS WITHOUT LESIONS AND THAT WAS BASICALLY DRIVEN BY LESS UNLEARNING WHEN WE INTRODUCED THE MEDIUM HEAT TRIALS. SO, BASICALLY WHAT WE FIND IS THAT THE GROUPS DID DIFFER IN TERMS OF EXPECTANCY WHERE PATIENTS EXPECTED LARGER DIFFERENCES AS A FUNCTION. WE TESTED HOW THIS MODULATED MEDIUM HEAT PAIN. AND FOCUSING SPECIFICALLY ON PAIN AND UNPLEASANTNESS WE SEE THAT RESPONSES TO LOW INTENSITY STIMULI IN YELLOW AND HIGH INTENSIVE STIMULI IN RED ARE THE SAME BETWEEN THE GROUPS SHOWING THAT PAIN SENSATION IS NOT ALTERED, AND WHEN WE LOOK AT RESPONSES TO THE CRITICAL MEDIUM HEAT TRIALS, CLICK ONCE MORE, WE FIND PATIENTS WITH LESIONS REPORT LARGER DIFFERENCES AS A FUNCTION OF CUE SO BASICALLY THEY'RE REPORTING HIGHER HEAT. SO, THIS SUGGESTS THAT THE LESIONS ACTUALLY ENHANCE EXPECTANCY EFFECTS ON PAIN. WE TEST TESTED THIS MARKER. WHAT WE FOUND IS THAT VMPFC LESIONS DID HAVE OUGHT KNOT I CAN RESPONSES BUT NOT THE PAIN PREDICTIVE CUES. WHEN WE NORMALIZE THAT AND ACCOUNT FOR THE FACTS THAT PATIENTS ARE DOWN OVER ALL THEY SHOW HIGHER WHEN MEDIUM HEAT IS PROCEEDED BY THE HIGH PAIN CUE RELATIVE TO THE LOW PAIN CUE. CLICK AGAIN. WE CAN SEE THIS ALSO WHEN WE LOOK AT THE RAW RESPONSES AND SO YOU CAN SEE THIS IS MEDIUM HEAT PROCEEDED BY THE HIGH IN ORANGE AND THE LOW PAIN CUE IN GREN AND YOU CAN SEE BOTH GROUPS ARE SHOWING ELEVATED SKIN CON ACCEPTANCE A PAIN PREDICTIVE CUE AND THE CORRESPONDENCE BETWEEN AROUSAL AND IT'S INTACT WITH PATIENTS. THAT THE LESIONS ENHANCE THE EFFECTS ON PAIN AND DIFFERENCES IN EXPECTATIONS ARE PRIOR TO LEARNING BASED ON INSTRUCTION AND WE SEE STRONGEST EFFECTS AND PERCEIVED UNPLEASANTNESS AND THERE'S NO DIFFERENCE IN THE EFFECTS ON SKIN CONDUCT ANTS WHICH IS CONSISTENT -- INCONSISTENT WITH A MARKER HYPOTHESIS. AND SO OUR HYPOTHESIS GOING FORWARD IS THAT THIS MIGHT MEAN THAT THESE PATIENTS ARE RELYING MORE ON THE INSTRUCTIONS ABOUT UPCOMING PAIN AND LESSON THE ACTUAL LEARNING. AND WE KNOW FROM OUR OTHER WORK THAT INSTRUCTIONS CAN LEAD TO MODULATION THROUGH MECHANISMS SUCH AS ENHANCING RESPONSES IN THE PREFRONTAL CORTEX THAT MIGHT BY PASS THE PREFRONTAL CORTEX TO ENGAGE SUB CORTICAL CIRCUITS THAT EFFECT AROUSAL. OVER ALL, PAIN IS A DECISION-MAKING PROCESS THAT IS FACTORS AND MULTIPLE FACTORS DRIVE ON RESPONSES TO NOXIOUS STIMULI AND WE HAVE A BASIC RESPONSE TO THE STIMULUS BUT THAT CAN BE A LOT ALTERED BY CS AND THE LESIONS ENHANCE EXPECTANCY EFFECTS ON PAIN AND AUTONOMIC RESPONSES TO CUES ARE MEDIATED OUT OF THE VMPFC SO WITH THAT I WANT TO ACKNOWLEDGE MY COLLABORATORS AND MY FORMER POSTDOC AND THANK YOU FOR IN INVITING ME TO PARTICIPATE TODAY. THE NEXT SPEAKER IS DANIEL BAUER WHO WILL BE TALKING ABOUT A PERSON ORIENTED APPROACH TO RESEARCH ON PAIN AND PAIN MANAGEMENT. >> THANK YOU SO MUCH. I WANT TO SAY, I'M REALLY PLEASED TO BE HERE AND I APPRECIATE THE INVITATION TO GIVE A TALK HERE. I AM NOT A PAIN RESEARCHER MYSELF. I'M MORE OF A METHODOLOGIST FOCUSED ON DEVELOPMENTAL METHODOLOGY BUT I THINK THAT CAN BE AN ADVANTAGE BECAUSE SOMETIMES THE WAY RESEARCH MOVES FORWARD IS BY DIFFERENT SUB FIELDS INTERFACING WITH ONE ANOTHER AND DRAWING IDEAS FROM ONE ANOTHER SO I WILL INTRODUCE YOU TO AN IDEA THAT IS QUITE PREVALENT IN DEVELOPMENTAL SCIENCE AND HAS POTENTIAL TO OFFER A PERSON ORIENTED VIEWPOINT TO RESEARCH ON PAIN AND PAIN MANAGEMENT. AND SO IN THAT WAY IT BUILDS ON THE PREVIOUS PRESENTATIONS AND PARTICULARLY THE ARGUMENT THAT Dr. JENSEN MADE THAT WE NEED TO FOCUS MORE ON THE PERSON. THE PERSON AS A WHOLE AS OPPOSED TO VARIABLES OR TREATMENTS AS MECHANISMS IN PARTICULAR. SO, I'M GOING TO BEGIN BY TELLING WHAT YOU IS A PERSON ORIENTED APPROACH. AT LEAST AS DEFINED IN MY NECK OF THE WOODS AND WE'LL TALK A LITTLE BIT ABOUT SOME QUANTITIVE METHODS CAN BE USED TO OBTAIN A PERSON ORIENTED KIND OF RESEARCH ORIENTATION AND LATE IN CLASS AND PRO VILE ANALYSIS ARE WHO I FOCUS ON. I'LL GIVE YOU AN APPLICATION FROM MY AREA, DEVELOPMENTAL PSYCHOLOGY AND I'LL TALK ABOUT POTENTIAL APPLICATIONS IN THE WHOLE PERSON PAIN RESEARCH AND CLOSE OUT WITH SOME PROS AND CONS OF THIS APPROACH. SO, THE PERSON ORIENTED APPROACH COMES FROM DEVELOPMENTAL SYSTEMS THEORY AND HERE A LITTLE QUOTE ON THIS A DEVELOPMENTAL SYSTEM IS COMPRISED OF MULTIPLE LEVELS, BIOLOGICAL, PSYCHOLOGICAL, SOCIOLOGICAL, CULTURAL THAT ARE FUSED TO CREATE A FUNCTIONING WHOLISM, THIS FUSE REFLECTS HIGH LEVELS OF INTERACTION WITHIN AND BETWEEN LEVELS OF THE SYSTEM AND SO THERE ARE A COUPLE THINGS HERE THAT I THINK ARE USEFUL TO HIGHLIGHT. THIS IDEA THAT THINGS ARE INFUSED AND WE HAVE HIGH LEVELS OF INTERACTIONS AND THAT WE'RE TRYING TO CAPTURE A FUNCTIONING WHOLISM. THESE ARE THE CRITICAL IDEAS OF THE PERSON O ORIENTED APPROACH. IT'S THE THERAPY OF GILBERT. HE WAS AN ANIMAL RESEARCHER AND INTERESTED DOES DEVELOPMENT TAKE PLACE. WHAT ARE THE DIFFERENT FACTORS THAT CONTRIBUTE TO INDIVIDUAL DEVELOPMENT AND HE ARTICULATED THE LEVELS OF THE SYSTEM THAT HE WAS INTERESTED IN AND HE SAID WELL OVER THE COURSE OF DEVELOPMENT, THERE ARE THESE INTERACTIONS AND CO ACTIONS THAT OCCUR, THIS BY-DIRECTIONAL EFFECTS OF THESE SYSTEMS INTERACTING WITH ONE ANOTHER TO PUSH IT FORWARD SO THERE'S A MULTI LEVEL PERSPECTIVE AND IT'S AIN'TER ACTIVE AND WHOA SAY CO ACTIVE IT'S NIAAA NATURE AND AND AND THAT WE FIRST KNOW AND LEARN. WE THINK ABOUT NOVA AND WHAT WE'RE FOCUSED ON THERE IS VARIABLES, RIGHT. WHAT IS THE EFFECT OF A GIVEN VARIABLE ON AN OUTCOME AND IN THAT SENSE, IT'S RATHER WE'RE NOT LOOKING AT THE PERSON AS A WHOLE, WE'RE LOOKING AT A PARTICULAR VARIABLE. WHAT ARE THE INDIVIDUAL DIFFERENCES ON THAT VARIABLE AND WHERE DOES THIS PARTICULAR PERSON RANK RELATIVE TO OTHER PEOPLE ON THIS PARTICULAR VARIABLE. SO WHEN WE RUN SOMETHING LIKE A REGREREGRESSION MODEL, HOW ARE E CONTROLLING FOR ALL OTHERS, HOLDING ALL ELSE CONSTANT AND THAT'S A POWERFUL IDEA AND IT'S THE IDEA OF STATISTICAL CONTROL. I WANT TO KNOW WHAT IS THIS VARIABLE I CAN CONTROL FOR ALL OTHER VARIABLES AND HOLD THEM CONSTANT AND LOOK AT ITS UNIQUE EFFECT. IT'S A COOL IDEA AND VERY POWERFUL WE KNOW THINGS DON'T STAY CONSTRUCTOR S TANT. IT'S NOT THEIR VARIABLE SCORE ON ONE BUT THEIR CONFIGURATION OF A SET AND WHEN WE INCLUDE INTERACTIONS IN OUR MODEL, WE TALKED ABOUT HOW THESE SYSTEMS ARE HIGHLY THEY ARE LOW ORDER SO THE BUY LYNN Y'ALL ACTION AND GIVE X1 AND X1 THERE ARE TECHNIQUE THAT CAN RECOVER MORE COMPLEX INTERACTIONS PATTERNS BUT THE TECHNIQUES THAT WE GREW UP WITH LOW ORDER INTERACTIONS EFFECT. THEY SAY I'M NOT INTERESTING IN THIS VARIABLE CONTROL FOR ALL OTHERS BUT I'M INTERESTED IN PEOPLE AND PEOPLE ARE CHARACTERIZED BY THEIR VALUABLE OF SETS THAT ARE INTERESTED FOR THE PROCESS THAT WE'RE STUDYING SO WE LOOK AT CON FISSIONATION AND ON THESE VARIABLES THAT REFLECT PATTERNS OF FUNCTIONING YOU LET'S SAY YOU HAVE WE ARE LOOKING FOR THE SENSE AREAS AND THE AWAY WANT TO IDENTIFY THOSE LUMPS THAT REPRESENT PROTO TIP I CANAL PATTERNS OF INDIVIDUAL FUNCTIONING AND THE KINDS OF TOOLS WE USE ARE THINGS LIKE K MEANS CLUSTER ANALYSIS AND WHAT I AM EMPHASIS MODELS AND THESE FALL WITHIN THE REALM OF WHAT IS NOW REFERRED TO WIDELY AS YOU KNOW SUPERVISED PERSON AND THE MACHINE LEARNING LITERATURE. NEXT PLEASE. AND PROFILE ANALYSIS IS THAT WE HAVE K CLASSES OF INDIVIDUALS MIXED TOGETHER AND THE POPULATION AND WE DON'T KNOW WHO IS A MEMBER WE SAY I IF WE IDENTIFIED THESE PROFILES OF DIFFERENT INDIVIDUALS CAN WE PRO DICTIONARY WHO IS IN THAT CLASS AND SO WE ADD OUR PREDICTORS TO OUR MODEL AND WE SEE IF WE CAN PRO DICTIONARPREDICTWHO IS A MES AND WHAT ARE THE ASSOCIATED WITH BEING IN A PARTICULAR CLASS AND HOW DOES YOUR CLASS MEMBERSHIP INFLUENCE YOUR ULTIMATE OUTCOME ON SOME VARIABLE OF INTEREST. AND THE OTHER THING WE CAN DO WHICH IS REALLY COOL WE CAN SAY, HEY, I'VE GOT THESE PREDICTORS AND I KNOW RELATE TO MY OUTCOME OF INTEREST BUT DOES IT RELATE DIFFERENTLY FOR PEOPLE WHO SHOW DIFFERENT CONFIGURATIONS ON THESE INTEREST. AND SO THAT IS THE THE THIRD KIND OF RELATIONSHIP WE CAN LOOK AT IS A LATENT CLASS MODERATION MODEL. NEXT, PLEASE. SO JUST A VERY SIMPLE EXAMPLE FROM AN EARLY PAPER USING A PERSON ORIENTED APPROACH BY BOB CARRENS IN 199 AS 1989 AND HOW Y MIGHT RELATE TO HIGH SCHOOL DROP OUT. SO THE FEATURE OF INTEREST THAT HE HAS THAT HE WANTS TO IDENTIFY INDIVIDUALS ON, ARE AGGRESSION, ACADEMIC PERFORMANCE, POPULARITY IN THIS THING HE CALLED ALL-AMERICAN REFERRED TO AS OLE I AMANOLYMPIAN. SO HE IDENTIFIED THESE DIFFERENT PROFILES HERE AND I'M NOT GOING TO SPEND A LOT OF TIME ON THIS PLOT BUT IT'S SHOWING HOW THE LEVEL OF EACH OF THESE SOCIAL COMMENT TECOMPETENCY ANDTHE DIFD THE VARIABLE ORIENTED APPROACH IS WE SEE THERE ARE THREE LATENT CLASSES HERE THAT ARE SIMILAR IN THEIR ACADEMIC PERFORMANCE AND NOTICE THAT THEY ARE QUITE DIFFERENT IN THEIR PROBABILITY OF HIGH SCHOOL DROP OUT. WHY? IT'S THE OTHER VARIABLES. IT'S THE WHOLE PERSON THAT MATTERS NOT THE SCORE JUST ON THIS ACADEMIC VARIABLE. AND THEY'RE VERY SIMILAR AND SOME RESPECT ON AGGRESSION AND THEY ARE VERY SIMILAR ON ACADEMIC BUT THEY'RE DIFFERENT IN OTHER WAYS AND THIS IS VERY LOW IN POPULARITY AND ALL AMERICAN AND THEY'RE TRYING TO CHARACTERIZE AND THESE THREE CONFIGURATIONS AND RELATE TO THE ULTIMATE LIKELIHOOD OF DROP OUT. SO NOW HOW CAN THIS BE USED IN PAIN RESEARCH. WELL I DID A LITTLE BIT OF RESEARCH AND I WAS HELPED BY Dr. JENSEN SENDING A FEW OF HIS ARTICLES SO I APPRECIATE THAT AND I CAME ACROSS A FEW QUOTES THAT I THOUGHT REALLY HIGHLIGHT THE NEED FOR A PERSON ORIENTED APPROACH IN THIS AREA SO EACH PAIN PROBLEM IS UNIQUE AND NOT ALL PATIENTS WILL AND EVALUATE TREATMENT EFFECTIVENESS AND SO WE COULD IDENTIFY LATENT PROFILES THAT REPRESENT INDIVIDUALS AND WE CAN IDENTIFY FOR ANY GIVEN PATIENT WHICH PROFILE DO THEY BELONG TO EX WHAT MIGHT BE THE MOST APPROPRIATE TREATMENT. SO JENSEN CONSIDERED SOCIAL FACTORS AS POTENTIALLY IMPORTANT HERE SO BRAIN STATE, COGNITIVE CONTENT, COGNITIVE COPING, BEHAVIORS LIKE GUARDING, REST, SOCIAL SUPPORT AND OTHER ENVIRONMENTAL FACTORS AND THE FIRST STEP IN ANY KIND OF CONFIGURATIONAL PERSON ORIENTED APPROACH IS TO IDENTIFY WHAT ARE THE KEY FACTORS THAT CHARACTERIZE INDIVIDUALS THAT ARE RELEVANT FOR WHAT I'M TRYING TO STUDY. AND IN ANOTHER PAPER IN 2015, THIS IS SUPPOSED TO BE PERHAPS YOU WOULD SEE FOUR PATIENT PROFILES, A LIMIT PROFILE WITH AN EXCESS OF MALE ADAPTIVE COPING AND ACTIVATE PROFILE WITH A DEFICIT OF HELPFUL COPING AND ENHANCE PROFILE WITH STRONG BASELINE COPING WITH NEED OF ENHANCEMENT AND A COMBINATION PROFILE WITH BOTH AN EXCESS OF MALL ADAPTIVE COPING AND A LACK OF HELPFUL COPING SO WE CAN SEE DO THOSE SORTS OF PROFILES EMERGE FROM THE EMPIRICAL ANALYSIS AND IF THEY DO DOES THE TREATMENT VARY IN ITS EFFECTIVENESS ACROSS THE CLASSES AND DO WE CHOSE DIFFERENT TREATMENTS FOR DIFFERENT GROUPS? NEXT, PLEASE. SO WE CAN IMAGINE FOR SINCE AND THESE PATIENTS PROFILES IN ANY GIVEN SAMPLE THAT WE MIGHT HAVE OF A HETEROGENEOUS SET OF PATIENTS AND WE HAVE A TREATMENT STUDY FOCUSES ON HYPNOSIS FOR INSTANCE AND WE CAN SEE IT'S COGNITIVE THERAPY AND OR SOME COMBINATION OF TREATMENTS BUT THE IDEA SO TO KIND OF MOVE TOWARDS THIS IDEA OF A UNIQUE INDIVIDUAL AND TRYING TO TARGET TREATMENTS TOWARDS UNIQUE INDIVIDUALS AND WHILE WE CAN'T BUILD STATISTICAL MODELS NECESSARILY FOR A SINGLE PERSON, WE CAN MOVE TOWARDS THAT MORE I'D YO GRAPHIC APPROACH BY IDENTIFYING PROFILES AND SUBSETTING AND IDENTIFYING MEANINGFUL SUBGROUPS IN OUR POPULATION FOR WHOM WE MIGHT SEE DIFFERENTIAL EFFECTS. NEXT, PLEASE. THIS CLASS MODEL COULD BE USED AND FOR THE LIKELY OUTCOMES OF A GIVEN TREATMENT. BASED ON THESE KINDS OF FINDINGS, AND BASED ON A PATIENT AND IT BELONG TO ANY LATENT CLASS AND THEN WE CAN SAY OK, WELL, GIVEN TO THE PROBABILITY THEY CAN BELONG TO OTHERS AND IT IS A .8 OF ONE CLASS AND OF ANOTHER AND .1 PROBABILITY OF A THIRD AND A ZERO PROPER ABILITY OF A FOURTH, GIVEN THAT, WE MIGHT SAY MOST LIKELY THEY'RE IN THIS GROUP AND WE CAN TAKE THAT PROBABILITY AS WELL AS OUR DEMONSTRATED EFFECTIVENESS OF THE TREATMENT FOR INDIVIDUALS IN THAT CLASS, TO GENERATE AN INDIVIDUAL PRO DICTION OF TREATMENT EFFECTIVENESS FOR THAT PATIENTS. FOR THIS PATIENT IT WILL BE DIFFERENT WITH THAT CLASS BUT FOR A PATIENT WHO MIGHT HAVE A NEXT PLEASE. >> SO I THINK THAT IS A PRETTY COOL IDEA. IT GETS US CLOSER TO INDIVIDUALE INDIVIDUALIZE PERSONS AND HOW WE MIGHT HAVE TREATMENT BY VARIABLES AND NOW WE CAN LOOK AT TREATMENT BY PERSONS AND SO WE CAN INCLUDE VIS LOGICAL INDICATORS AND ASPECTS OF THE SOCIAL ENVIRONMENT AND SO FOURTH AND PROFILES FOR OUTCOMES RATHER THAN JUST LOOK AT ONE OUTCOME AT A TIME SO WE CAN HAVE PREDICTORS OF OUTCOMES. >> TWO MINUTE WARNING. WHETHER THEY'RE EFFECTIVE BETWEEN LATENT CLASSES AND SO WE CAN LOOK AT OVER TIME RESPONSES TO TREATMENT AND DO WE SEE DIFFERENT SUBSETS OF INDIVIDUALS RESPOND NORTH DIFFERENT WAYS TO TREATMENT AND SO DO YOU SEE AN EARLY IMPROVEMENT GROUP SO THERE ARE RELATED KINDS OF MODEL THAT'S LOOK AT THESE PATTERNS OF CHANGE AS WELL. NEXT, PLEASE. THIS IS OBVIOUSLY A LITTLE BIT OF SELF CITATION IN HERE WHICH IS ALWAYS FUN AND AND TO LOOK AT IF YOU ARE INTERESTED IN THIS APPROACH TO RESEARCH. AND THAT IT S IT FOR ME NEXT UP IS DAVID WILLIAMS AND THANK YOU VERY MUCH. >> GOOD AFTERNOON. I ENJOYED YOUR TALK. I'M GOING TO TALK ABOUT ASSESSING CHRONIC OVERLAPPING PAIN CONDITIONS WITHIN THE INDIVIDUALS AND NEXT SLIDE. JUST A COUPLE DISCLOSURES, I DO CONSULTING WITH COMMUNITY HEALTH FOCUS AND FUNDING FOR NIH. SO, WE'VE HEARD A LITTLE BIT TODAY ABOUT CHRONIC OVERLAPPING PAIN CONDITIONS AND JUST TO REMIND YOU, THE CONDITIONS THAT KIND OF FALL INTO THIS CLASSIFICATION WOULD BE THESE 10 CONDITIONS AND IRRITABLE BOWEL SYNDROME, CHRONIC LOW BACK PAIN, CHRONIC PROSTATITIS ALSO KNOWN AS UBPS AND HEADACHES AND PAINFULLEN ENDOMETRIOSIS AND FIBER MYALGIA AND MYALGIA OR CHRONIC FATIGUE SYNDROME SO THESE ARE THE 10 CONDITIONS THAT TEND TO FOLLOW INTO THIS CLASSIFICATION. SO THE QUESTIONS THAT ARE RAISED AND HOW THEY CAN BE LINKED AND WE SHOULD BE TREATING SEPARATELY OR SHOULD WE BE ADDRESSING SOME COMMON UNDERLYING CAUSE OF THE OVERLAP. NEXT SLIDE. WE RUN INTO A BARRIER AND THE BARRIER THAT WE RUN INTO IS THAT WE DON'T REALLY HAVE A RELIABLE AND VALID WAY OF ASSESSING AWFUL THESE CONDITIONS IN THE SAME INDIVIDUAL AND THE UNTHINKABLE WAY WOULD BE TO HAVE A COLLISION DELIVER ALL 10 CRITERIA TO THE SAME CRITERIA AND IT WON'T HAPPEN IN THE REAL WORLD. AND MORE COMMONLY WHAT HAPPENS IN CLINICAL PRACTICE IS IF YOU HAVE JAW PAIN YOU GO TO YOUR DENTIST AND THE DENTIST ASKS YOU ABOUT YOUR JOB JAW PAIN AND ABOUT OFFERS TREATMENTS FOR JAW PAIN AND IT'S PROBABLY UNLIKELY TO ASK ABOUT PELVIC PAIN. AT THE SAME TIME, WITH THE PERSON GOES OVER TO THEIR G.I. DOCTOR AND G.I. DOCTOR WILL ASK ABOUT THEIR GUT AND OFFERS TREATMENTS FOR IBS AND GUT DISTRESS AND AGAIN IS PROBABLY NOT GOING TO BE ASKING ABOUT OTHER AREAS OUTSIDE OF THEIR SPECIALIZATION. SO SIMILARLY IF THE PERSON GOES TO NEUROLOGIST WITH HEADACHES, THEY'RE LIKELY TO ASK ABOUT HEADACHES THEY WON'T ASK ABOUT OTHER CONDITIONS THAT THE PERSON MAY HAVE. SO, AS A CONSEQUENCE WE TEND TO HAVE A LOT OF INDEX CONDITIONS AND THIS IS THE CONDITION THAT THE PERSON GETS DYING KNOWED WITH AND AT LEAST INITIALLY AND MANY TIMES IF YOU LOOK AT SOMEONE'S CLINICAL RECORDS, YOU WILL SEE THAT THEY'VE BEEN TO MANY DIFFERENT DOCTORS, EACH GETTING INDIVIDUAL DIAGNOSIS BUT NOT NECESSARILY SEEING ANY LINKAGE BETWEEN THESE AND THERE HAVE BEEN A COUPLE OF LARGE WHERE THEY WERE ADULT AND WE GOT A HANDLE ON SOME OF OVERLAP AND EVEN THOSE VERY LARGE NETWORKS IN STUDIES DID NOT A SASS ALL THREE WITH THE SAME INDIVIDUAL AND NEXT LIED, PLEASE. AND JUST TO GIVE AN EXAMPLE OF HOW IMPORTANT IT CAN BE THEY LOOKED AT 424 PATIENTS WITH PELVIC PAIN AND WE'RE DYING KNOWS WITH CHRONIC PROSTATE US AND EVEN THOUGH THEY CAME IN, WITH THIS AS THEIR INDEX CONDITION, ONLY 25% ONLY HAD PAIN IN THE PELVIC REGION THEY EXTENDED BEYOND JUST THE BELL VICTIM REGION WITH THIS DIAGNOSIS. IT'S ONE TO TWO TO THREE TO SOUTHERN REGIONS AND DESCRIBING MORE WIDESPREAD PAIN AND 38% QUALIFIED FOR WIDESPREAD PAIN EVEN THOUGH THEY CAME IN ONLY EXPECTING TO HAVE ONE CONDITION WHICH WOULD BE PELVIC PAIN AND OTHER TYPES OF PROBLEMS AND CORE QUALITY OF LIFE AND NEXT SLIDE, PLEASE. WHAT I'M GOING TO DO BRIEFLY TODAY IS DESCRIBE TWO METHODS AND PAIN CONDITIONS AND FOR CLINICAL RESEARCH AND THE FIRST USE NOT THE COMPUTE ABLE PHENOTYPE APPROACH AND THIS IS FOR USE IN ADMINISTRATIVE DATABASES AND THEN THE SECOND IS THE CHRONIC OVERLAPPING PAIN CONDITIONS. NEXT SLIDE. IF YOU HAVE AN ADMINISTRATIVE DATABASE AND YOU WANT TO TAKE A LOOK AT AND THIS IS A STUDY THAT WAS LED BY ANDREW FROM THE UNIVERSITY OF MICHIGAN AND BY VI FAWN WHO WAS AN UNDERGRADUATE AND IS NOW IN MEDICAL SCHOOL AT GEORGETOWN. THIS STUDY HAD SEVERAL PARTS TO IT AND WE DID ASSEMBLE AN EXPERT PANEL AND WE HAD THREE EXPERTS SO 30 EXPERTS AND THESE WERE INDIVIDUALS WHO FOCUSED ON THE SPECIFIC CHRONIC OVERLAPPING PAIN CONDITIONS AND MANY TIMES WHERE PEOPLE WHO ARE INVOLVED IN THE DEVELOPMENT OF THE DIAGNOSTIC CRITERIA AND WE HAD THEM RECOMMEND ICD CODES THAT WOULD MAP ONTO THE VARIOUS CONDITIONS OF INTEREST AND WE THEN ALSO DID A NATURAL LANGUAGE PROCESSING APPROACH WHERE WE LOOKED FOR THE MEDICAL RECORDS FOR DESCRIPTIVE TERMS FOR THE OVERLAPPING PAIN CONDITIONS AND THEN WENT IT MAKE SURE WE CAN MAP THOSE DESCRIPTIVE TERMS WITH THE CODES ACODES FORT INDIVIDUA. WE RETAINED THAT CODE WHEN WE FOUND THE CODE LINING UP WITH THE DESCRIPTION IN THE CHARTS. AND THEN FINALLY WE IN ONE MEDICAL SYSTEM WE DID A DEMONSTRATION PROJECT WITH 12,000 INDIVIDUALS AND USING THE RETAIN CODES TO TAKE A LOOK AT THE DEGREE OF OVERLAP THAT WAS GOING TO BE PRESENT AND IN THESE CONDITIONS. THIS WAS LITTLE CONTROVERSY AND ONLY ONE CODE AND THE AGREEMENT THERE WAS GREAT AND IN OTHER CONDITIONS, WHERE THERE WAS LESS AGREEMENT ON THE DIAGNOSTIC CRITERIA AS WELL AS THE CODES, THAT WAS GREATER RELIANCE MAKING SURE WE HAD ALIGNMENT BETWEEN THE ICD CODES AND THE DESCRIPTIVE TEXT AND THE CHARTS. NEXT SLIDE. THIS IS A CHART. WE SAW A SIMILAR ONE IN Dr. SAWSAN AS-SANIE TALK EARLIER FROM THE SAME ARTICLE. SHE WAS SHOWING ODDS AND RATIO AND THIS LOOKED AT THE PERCENTAGE OF OVERLAP IN THE VARIOUS CONDITIONS WHERE THE INDEX CONDITIONS AND AGAIN, WHAT WE'VE NOTICED FROM THIS IS THAT WHILE THESE CONDITIONS DO ALL TEND TO OVERLAP WITH EACH OTHER MORE THAN THE CONTROL CONDITIONS, THE LAST THREE ON THE BOTTOM, COPD, AND CARDIOVASCULAR DISEASE, DIABETIC MEASURE ON AGENT' WE SEE THERE'S LITTLE OVERLAP WITH THE CONTROL CONDITIONS BUT THERE'S A LOT OF OVERLAP AMONG THESE 10 CONDITIONS. AND SOME TEND TO OVERLAP MORE THAN OTHERS, FIBER MYALGIA AND IRRITABLE BOWEL OR FIBER MYALGIA LOW BACK PAIN WITH HEADACHE AND IBS AND UCPCS WITH HEADACHE FOR EXAMPLE ANDEN DOUGH WITH MIGRAINE HEADACHE. SO WITH DO SEE SOME CONDITIONS HAVE A HIGH DEGREE OF OVERLAP AND OTHERS LESS SO AND SOME HAVE A SPECIFIC OVERLAP AND SOME CONDITIONS AND ABOUT WHAT IS INTERESTING THOUGH, IS THAT WHEN THE OVERLAP DOES OCCUR, IT'S USUALLY SOME OTHER REGION OF THE BODY, FOR EXAMPLE, HAVING PELVIC PAIN AND HEADACHES AS WELL. NEXT SLIDE, PLEASE. SO, THESE SECOND APPROACH I WANTED TO TALK ABOUT IS THE CHRONIC OVERLAPPING PAIN CONDITIONS AND THIS IS A SCREENER THAT WE HAD BEGIN USED THAT SAME PANELIST 30 EXPERTS TO GIVE US ADVISE ON THE DIAGNOSTIC CRITERIA AND WE WANTED TO MAKE SURE THAT WE COULD, VERY EFFICIENT LIKE ADMINISTERED THE 10 DIAGNOSTIC CRITERIA TO ANY GIVEN INDIVIDUALS AND TO HELP US TRIAGE THAT WE USE A BODY MAP AND SHOWN ON THE SLIDE AND SO WE HAVE PEOPLE COMPLETE THE BODY MAP. IF THEY DON'T INDICATE HEADACHE FOR EXAMPLE, THEN WE WILL NOT ADMINISTERED THE HEADACHE CRITERIA TO THAT INDIVIDUAL WHO IS NOT SOME PLACE THEY'RE EXPERIENCING PAIN BUT ANY REGION WHERE THEY DO INDICATE PAIN AND IT'S A RELEVANCE TO THE DIAGNOSTIC CRITERIA THEN WE WILL ADMINISTERED THE PUBLISH DIAGNOSE TICK CRITERIA OR THE MODIFIED CRITERIA TO THEM. WE HAVE WORKED TO MAKE SURE THAT THIS IS A LOGIC-DRIVEN APPROACH AND SO AS SOON AS SOMEONE IS NOT GOING TO QUALIFY FOR THE DIAGNOSTIC CRITERIA, THEY CAN BAIL OUT OF THAT AND THEY MOVE ONTO THE NEXT CRITERIA. WHAT WE FIND IS THAT FOLKS ARE ABLE TO USUALLY GET THROUGH THIS IN ABOUT 10 MINUTES SO IT DOESN'T TAKE A GREAT DEAL OF TIME SO IT'S A LOT MORE EFFICIENT THAN ADMINISTERED ALL THE CRITERIA TO ANY GIVEN INDIVIDUAL AND AT THE END, WE'RE ABLE TO GET A REPORT THAT COMES OUT AND THAT BASICALLY TELLS YOU WHETHER YOU QUALIFY OR NOT FOR EACH OF THE CONDITIONS AND THEN IT TELLS YOU HOW MANY OF THE CONDITIONS YOU QUALIFY FOR BASED ON THIS SCREENER. NEXT SLIDE, PLEASE. AND THE SCREENER IS NOW IN VERSION 11. VERSION 11 IS A VERSION THAT'S ABLE TO RUN ON RED CAP. THIS WAS A REQUEST THAT WOULD BE PUT INTO RED CAPS OF MORE UNIVERSITIES AND MORE INSTITUTIONS WOULD BE ABLE TO TAKE ADVANTAGE OF THIS SCREENER AND SO THIS COMPANY IS YOUR GUIDE THAT TALKS ABOUT THE DEVELOPMENT OF THE COPC SCREENER AND LISTS OF ITEMS AND SCORING AND THE OUTPUT AS WELL AS THE VALIDATION PROPERTIES AND THIS LATEST VERSION HAS GONE THROUGH ADDITIONAL VALIDATION AND WE'VE WORKED WITH A LOT OF PATIENT GROUPS AND WE HAVE A LOT OF PATIENT INPUT AND FOR EXAMPLE ON THE BODY MAP, YOU PROBABLY NOTICED THE COLORING OF THE BODY MAP AND THIS WAS THE RECOMMENDATION OF OUR PATIENT GROUPS SO PEOPLE WHO MIGHT BE COLOR BLIND WOULD BE ABLE TO USE IT AND WE ACTUALLY DID THE UNTHINKABLE IN THE VALIDATION WHERE WE ACTUALLY HAD CLINICIANS DELIVER ALL 1 10 DIAGNOSTIC CRITERIA TO THE SAME INDIVIDUAL AND WE HAD FOLKS IN EACH WHAT THE CLINICIANS WERE GETTING AND WHAT WE GOT WITH OUR A GROVATED STRAINER. IF YOU ARE INTERESTED IN ACCESSING THE SCREENER, THERE'S A WEBSITE AND WE HAVE SEVERAL THINGS. WE HAVE A DEMONSTRATION OF SOMEONE USING THE SCREENERS SO IF YOU WANT TO SEE HOW THAT'S DONE, THE USER GUIDE WHICH I JUST REFERRED TO IS AVAILABLE FOR DOWNLOAD AND THERE'S AN ON-LINE DEMONSTRATION -- TO FOLKS WHO WANT TO USE IT AND THE REQUIREMENT IS YOU HAVE TO HAVE RED CAP IN ORDER TO USE IT. NEXT SLIDE, PLEASE. AND AGAIN HERE IS THE URL. IF YOU DO YOU CAN ACCESS THIS FOR FREE IF YOU ARE AN ACADEMIC USER. I'LL STOP THERE. THANK YOU. >> THANK YOU ALL FOR MY PANEL MEMBERS. WE HAVE VERY INTERESTING FOUR PRESENTATIONS. IT'S VERY DIFFERENT FROM OUR FIRST PANEL DISCUSSION THIS MORNING. NOW THE FIRST PANEL DEFINITELY INDICATED THE NEED TO GO ABOVE AND BEYOND WHAT THE MAINSTREAM SO WHAT CURRENTLY IS A WAY OF LOOKING TO THE PAIN AND EMPHASIZE THE NEED TO HAVE A WHOLE-PERSON APPROACH. NOW, FOR THIS PANEL, WE STARTED WITH JENSEN'S OVERVIEW INDICATING ABOUT THE APPROACHES, ABOUT THE TOOLS AND ALL THE THE DIRECTIONS, WHAT WE CAN DO TO ADDRESS THE ISSUE RAISING THE FIRST PANEL. Dr. ATLAS PROVIDE HER RESEARCH DATA USING BRAIN IMAGING THAT CAN SERVE AT LEAST TWO THE WAY I SEE IT. ONE TO IDENTIFY THE BRAIN SUBSTRATES, YOU KNOW, BRAIN CIRCUITRIES THAT MAY PLAY IMPORTANT ROLES IN PAIN MANAGEMENT THAT BEYOND TO THE PAIN SENSORY AND TO EVOLVE EFFECTIVE PART OF THE PAIN AND ALSO THEY HAVE POTENTIAL WERE INFORMED THE HOW WE CAN PREDICT PAIN USING DIFFERENT APPROACHES AND IT'S NOT NECESSARY TO SAY THAT WE HAVE TO USE BRAIN IMAGING AS A PREDICT OR BUT THEN THESE INFORM THE DIRECTIONS. AND OF COURSE, WE HAVE Dr. BAUER GIVE US A VERY INTERESTING IDEA. THIS IS HER EXPERTISE AND WHAT WE CAN USE IN TERMS OF METHODOLOGY WIDE TO LOOK INTO SOME DIFFERENT ANGLES INTO THE QUESTIONS THAT WE ARE ASKING ABOUT THE DAY AND FINALLY, IN A THE IDEAS STARTING FROM THE CHRONIC OVERLAPPING PAIN COMMISSIONERS AND USE THIS AS EXAMPLES AND INTRODUCE US ABOUT SCREENERS WITH THIS LET'S COME TO THE DISCUSSIONS AND WE HAVE A FEW EXTRA MINUTES BEYOND WHAT WE'RE ASSIGNED FOR. BECAUSE A FEW QUESTIONS ARE SIMILAR APPROACHES AND FOR EXAMPLE, EMPHASIZING SO WE START FROM THIS QUESTION AND IT'S FOR Dr. JENSON, SAYS IT'S UNLEARN HOW YOU CAN DETERMINE BETWEEN THE MECHANISMS IN THE MEDIATION AND ANALYSIS WHERE THERE'S NOT ENOUGH POWER FOR THOSE MECHANISTIC OUTCOMES OR IT COMES FROM THE SECONDARY OUTCOMES BECAUSE THE TRIALS ARE POWERED FROM THE PRIMARY CLINICAL OUTCOME. CAN YOU EXPLAIN THE POWER ISSUES HERE? I NEED TO REPEAT? >> I THINK WE'RE GOOD. THAT'S A FANTASTIC QUESTION AND GETS AT THE CRUX OF THE ISSUE OF DOES THIS ONE STUDY, CAN WE USE THIS ONE STUDY TO ANSWER A SERIES OF QUESTIONS AND THE ANSWER TO THAT I THINK IS NO AND MY VIEW IS THAT A SINGLE STUDY IS USUALLY DESIGNED TO ANSWER ONE QUESTION, IT'S USUALLY POWERED FOR THAT. WE CAN SHIFT OUR VIEW FROM THINKING OF HAVING, SPENDING ALL THIS MONEY AND ALL THIS RESOURCES TO ANSWER ONE QUESTION AND TO ASKING OURSELVES TO DESIGN STUDIES THAT CAN CREATE ANSWERS TO MULTIPLE QUESTIONS AND SO NOT GET A DEFINITIVE ANSWERS BUT EFFECT SIZE SO, YOU KNOW, THE ROLE OF SELF-EFFICACY AS TO EXPLAIN THE BIO FEED BACKS IMPACT ON HEADACHE IN THIS STUDY THAT IS .38 AND IF WE INCLUDE THESE ANALYSIS ACROSS MULTIPLE STUDIES, WE'LL SEE MULTIPLE EFFECT SIZES .1, .38, .45, .12, ET CETERA, AND WE'LL OVER TIME, UNDERSTAND WHAT IS THE EFFECT, WHAT IS THE ROLE OF THIS AS A MECHANISM WHEN YOU EXAMINE A CROSS MULTIPLE STUDIES, SO, POWER, HE WANT TO POWER STUDIES TO BE ABLE TO CREATE RELIABLE EFFECT SIZES. NOT TO ANSWER A DEFINITIVE QUESTION. THE POWER QUESTION GETS TURNED ON ITS HEAD HERE. I'M ADVOCATING FOR A SHIFT HOW WE I THINK WE SHOULD GET RID OF THE P VALUE AND THINK ABOUT IT DIFFERENTLY. I WOULD LOVE TO HEAR DR. BAUER'S RESPONSE ON IT, BECAUSE I THINK WE MAY BE CONSTRAINED BY WHAT I'M CALLING IN MY VIEW THE TYRANNY OF THE P VALUE. PRACTICALLY, WE NEED TO GET OUR RESEARCH FUNDED SO I WILL OFTEN IN MIGRANTS SAY WE'RE GOING TO TEST THIS ONE QUESTION AND WE'RE POWERED FOR T BUT BY THE WAY, WE'RE GOING TO DO SECONDARY ANALYSES TO GET THESE ESTIMATES THAT FUTURE RESEARCHERS AND SCIENTISTS CAN USE. SO THAT'S MY THINKING. BUT IT'S A LONG CONVERSATION. >> ANY COMMENT, DR. BAUER? >> SURE. I MEAN, THERE HAVE BEEN A FEW MOVEMENTS AFOOT IN SCIENCE, PARTICULARLY IN PSYCHOLOGY, TO TRY TO BAN P VALUES, AND THE PROBLEM SEEMS TO BE FINDING, YOU KNOW, ENOUGH PEOPLE TO BUY IN TO THAT MOVEMENT AND THEN FINDING GOOD ALTERNATIVES. FOR A WHILE, PEOPLE SAID, OH, WE COULD DO CONFIDENCE INTERVALS. CONFIDENCE INTERVALS ARE BETTER. SURE, BUT TO GET YOUR TEST STATISTIC FOR THE P VALUE, YOU'RE JUST TAKING AN ESTIMATE AND DIVIDING BY THE STANDARD ERROR, IT'S REALLY NOT TREMENDOUSLY DIFFERENT IN TERMS OF THE KIND OF INFORMATION THAT'S BEING GIVEN THERE, BUT I DO, YOU KNOW, CERTAINLY AGREE THAT A GREATER FOCUS ON EFFECT SIZES IS IN ORDER, AND OFTENTIMES IN ALL HYPOTHESES, WE TEST WITH P VALUES, CAN BE A BIT SILLY AND NOT THAT INFORMATIVE, AND SO I THINK IT'S ALL TO THE BETTER TO FOCUS ON THOSE EFFECT SIZES AND TO TRY TO AGGREGATE INFORMATION ACROSS STUDIES BY HAVING KIND OF STANDARDIZED EFFECT SIZES THAT WE CAN LOOK AT. SO I DEFINITELY LIKE THOSE IDEAS. I DON'T KNOW IF THE P VALUE WILL EVER BE BANNED, BUT WE CAN CERTAINLY COMPLIMENT IT WITH MORE FOCUS ON EFFECT SIZES. >> THANK YOU, DR. BAUER. NOW, THIS AGAIN IS ANOTHER QUESTION RELATED TO -- DIRECT TO DR. JENSEN. YOU MAY HAVE ALREADY ANSWERED IN PART, AT LEAST PARTIALLY THE QUESTION BUT LET ME THROW IT OUT ANYWAY JUST IN CASE YOU HAVE A DIFFERENT -- THE QUESTION IS, WITH THE ABILITY TO EXAMINE MANY -- FACTORS IN -- ANALYSIS, HOW DOES ONE ASSURE SUFFICIENT POWER TO EXAMINE ALL FOUR OF THOSE INDIVIDUAL CHARACTERISTICS? >> SO YOU'RE ABSOLUTELY RIGHT, THAT THAT, IN MY VIEW, IS A DIFFERENT WAY OF LOOKING AT THE SAME QUESTION, THAT I DON'T THINK WE DO HAVE THE POWER, IF WE'RE THINKING IN TERMS OF P VALUES, TO EXAMINE 30 RELATIONSHIPS. WHAT WE DO IS, IF A STUDY IS DESIGNED WELL, ARE RELIABLE MEASURES, ADEQUATE SAMPLE SIZE TO BE ABLE TO CREATE RELIABLE EFFECT SIZES THAT THEN CAN BE EVALUATED -- REPLICATED IN OTHER STUDIES. SO IF A CERTAIN MECHANISM EMERGES AS HAVING A POWERFUL EFFECT ACROSS STUDIES REGARDLESS OF THE POWER IN EACH OF THOSE INDIVIDUAL STUDIES, WE CAN PROBABLY TRUST, YOU KNOW, THAT'S A PRETTY IMPORTANT VARIABLE. SO I DON'T THINK WE SHOULD -- IN MY VIEW, AGAIN, IT'S GOOD TO HAVE A SINGLE PRIMARY ANALYSIS, A SINGLE PRIMARY OUTCOME, WE CAN TEST THAT DEFINITIVELY, ANSWER THE QUESTION YES OR NO, BUT MY PERSONAL INTEREST IS ALWAYS IN THE SECONDARY ANALYSES, TO SEE WHAT I CALL DISCOVERY ANALYSES. WHICH THEN CAN LEAD TO INFORMED FUTURE RESEARCH. SO MY ANSWER TO THE QUESTION, HOW DO YOU HAVE ADEQUATE POWER? YOU CAN'T. BUT I DON'T THINK THAT'S THE IMPORTANT QUESTION HERE. THE IMPORTANT QUESTION IS, WHAT'S HAPPENING HERE, AND WHAT'S HAPPENING WITH THESE PEOPLE, AND IN OUR ONE STUDY WE SAY THIS IS WHAT LOOKS LIKE IS LAPPING AND THEN WE DO ANOTHER STUDY TO SEE, HEY, OF THOSE 10 THINGS, SEVEN SEEM TO BE HAPPENING ACROSS TWO -- AND THOSE THINGS REPLICATE. THAT'S THE STUDY OF SCIENCE OVER TIME, I THINK. >> THAT'S INTERESTING. IF WE HAVE TIME, WE'LL BRING BACK THIS QUESTION AGAIN BECAUSE I HAVE SOME RELATED QUESTIONS, AND SOME THOUGHTS. BUT FOR NOW, LET'S MOVE TO A QUESTION, HOW DO WE MEASURE TREATMENT EXPECTANCY IN CLINICAL SETTINGS? CAN YOU SHARE YOUR COMMENTS? >> THERE ARE A NUMBER OF QUESTIONNAIRES THAT EXIST TO BE ABLE TO ASK QUESTIONS ABOUT THE -- THEY'VE HAD IN ADVANCE OF A PROCEDURE. BUT ONE OF THE APPROACHES THAT I THINK IS MOST EXCITING THAT HAS EXISTED FOR A LONG TIME BUT BECAUSE IT REQUIRES DECEPTION IS A LITTLE BIT TOUGH TO USE, IS WHAT'S CALLED THE BALANCED PLACEBO DESIGN IN THE CONTEXT OF CLINICAL TRIALS. AND THERE, WHAT YOU CAN DO IS, RATHER THAN JUST HAVING A TREATMENT AND A PLACEBO ARM, YOU CAN CROSS THE ADMINISTRATION OF THE TREATMENT WITH KNOWLEDGE ABOUT THE TREATMENT. SO BASICALLY PEOPLE CAN RECEIVE A TREATMENT WHEN THEY KNOW THEY'RE GETTING IT, OR WHEN THEY BELIEVE THEY'RE NOT RECEIVING A TREATMENT, AND LIKEWISE, WE CAN RECEIVE PLACEBO WHEN YOU BELIEVE YOU'RE RECEIVING A TREATMENT OR BELIEVE YOU'RE NOT RECEIVING A TREATMENT. AND THIS ALLOWS YOU TO SEPARATE OUT THE EFFECTS OF THE TREATMENT ITSELF FROM BELIEF IN THE TREATMENT. AND SO I'M -- I THINK IT USES -- IT LEVERAGES CAUSAL MANIPULATIONS TO ACTUALLY UNDERSTAND HOW EXPECTATIONS COMBINE WITH DIFFERENT TYPES OF TREATMENTS. AND WE'VE SHOWN THAT EXPECTATIONS OR KNOWLEDGE ABOUT DRUG DELIVERY HAVE ADDITIVE EFFECTS WITH THE NEW OPIOID AGONIST BUT DIFFERENT TYPES OF TREATMENTS SEEM TO HAVE DIFFERENT TYPES OF COMBINATIONS WITH EXPECTANCY. SO BASICALLY I WOULD OFFER THAT AS SOMETHING THAT I WOULD HOPE MORE AND MORE RESEARCHERS THINKING ABOUT DIFFERENT INTERVENTIONS CAN THINK ABOUT CAN YOU ALSO ISOLATE MECHANISTICALLY THE CONTRIBUTION OF EXPECTANCY, AND THEN, OF COURSE, YOU CAN ADD THOSE INDIVIDUAL DIFFERENCE -- QUESTIONNAIRES AND THINGS LIKE THAT ON TOP AS PERSON LEVEL MODERATORS. >> THIS IS A QUESTION, VERY SHORT, HOPEFULLY IT WILL BE AN EASY ANSWER. IT SAYS, HAS THE COPCs, THE CHRONIC -- SCREENER, SORRY, COPC SCREENER BEING TRANSLATED? I'M NOT SURE TRANSLATED HERE MEANS FROM RESEARCH TO CLINIC OR SOME OTHER TRANSLATIONS. BUT LET ME THROW IT OUT. >> I ASSUME IT -- HAS IT BEEN TRANSLATED INTO OTHER LANGUAGES. CURRENTLY, NO, RIGHT NOW IT'S ONLY IN ENGLISH, BUT I ASSUME THE TRANSLATION INTO OTHER LANGUAGES IS SOMETHING THAT PEOPLE WILL BE INTERESTED IN DOING. WE'RE OPEN TO THOSE COLLABORATIONS. >> THERE IS ANOTHER SHORT ONE DIRECT TO YOU. WILL THE COPCs WORK IN ONCO? >> RIGHT, THAT'S PROBABLY -- THAT'S ANOTHER PLATFORM. CURRENTLY, THE VERSION 11, WHICH IS THE MOST RECENT VERSION THAT HAS BEEN VALIDATED, IS ONLY AVAILABLE IN REDCAP. WE DO HAVE PLANS TO MAKE A QUALTRICS VERSION AND PROBABLY ANOTHER VERSION IN OTHER PLATFORMS, BUT RIGHT NOW IT'S ONLY AVAILABLE IN REDCAP. >> ALL RIGHT, THANK YOU. THIS IS -- NEXT QUESTION PROBABLY CAN BE DIRECT TO ANY ONE OF MY PANEL MEMBERS. IT SAYS, THANK YOU ALL FOR YOUR WONDERFUL TALKS IN ADDITION TO -- WHAT ARE SOME OTHER STUDY DESIGN AND METHODOLOGICAL CONSIDERATION FOR STUDIES IN WHICH AN INVESTIGATOR MIGHT WANT TO USE -- AND THE LATENT CLASS AND PROFILE ANALYSIS? ANYONE LIKE TO TAKE A LEAD? >> I'LL JUMP IN JUST BECAUSE I HAD SOME THOUGHTS. ONE IS, I'M SORRY THE QUESTION WAS ASKED LIKE THAT BECAUSE I THINK IN MY VIEW, THE FIRST THREE ISSUES ARE SAMPLE SIZE, SAMPLE SIZE AND SAMPLE SIZE. SO THAT'S JUST CRITICAL. AND THEN, YOU KNOW, HOW MUCH OF A SAMPLE SIZE, I DEFER TO MY STATISTICIAN EXPERTS, BUT THE ANSWER I OFTEN GET IS, MORE. BUT THE SECOND ISSUE IS THAT I WOULD -- THE SELECTION OF THE MEASURES BE THEORY-DRIVEN. BY THAT, I MEAN SO MANY OF PRIOR MODERATION ANALYSES EXAMINE THE MODERATORS OF CONVENIENCE, THE ONES YOU HAPPEN TO HAVE ASSESSED. DEMOGRAPHIC VARIABLES, MAYBE OUTCOME VARIABLES AT BASELINE, BUT WHEN YOU DO IT THAT WAY, THE CHANCES OF FINDING SOMETHING THAT'S OF IMPORTANCE ARE LIMITED, AND PROBABLY NOT REPLICABLE. SO THE IMPORTANT ISSUE IS TO THINK AHEAD OF TIME BASED ON OUR THEORIES AND BASED ON OUR CLINICAL EXPERIENCE EVEN, WHAT ARE THE MODERATORS AND MEDIATORS? WHY DO WE THINK THIS WORKS? AND THEN FOR WHOM DO WE THINK THIS WORKS, AND WRITE THOSE DOWN, AND THEN FIND THE BEST, MOST RELIABLE MEASURES OF THOSE THINGS. PERSONALLY, I OFTEN MAKE THAT LIST AND THEN I ASK MYSELF, HOW MIGHT IT WORK? SO THEN I HAVE KIND OF EXPLORATORY ONES. DISCOVERY ONES. AND SO WE MIGHT ADD SOME MEASURE TO THOSE JUST TO SEE TO START TO BUILD THE EMPIRICAL BASE. SO THE FOUR ISSUES: SAMPLE SIZE, SAMPLE SIZE, SAMPLE SIZE, AND THEORY. >> SAMPLE SIZE, SAMPLE SIZE, SAMPLE SIZE, AND THEORY. GREAT. >> IF I COULD -- IS IT OKAY IF I ADD TO THAT, DR. LIN? >> PLEASE GO AHEAD. >> I WAS GOING TO ECHO DR. JENSEN'S COMMENT ABOUT FIND THE MOST RELIABLE MEASURES POSSIBLE FOR THE THINGS YOU'RE INTERESTED IN. I THINK SOMETIMES WHEN WE ARE FIRST EXPOSED TO POWER ANALYSIS AND THINK ABOUT POWER, WE THINK, OH, POWER IS A FUNCTION OF EFFECT SIZE AND POWER IS A FUNCTION OF SAMPLE SIZE. IT'S INCLUDED IN RELIABILITY BECAUSE IF YOU HAVE A POOR MEASURE THAT HAS A LOT OF NOISE IN T THAT'S VARIABILITY YOU'LL NEVER PREDICT SO YOUR EFFECT SIZE GOES DOWN SIMPLY DUE TO POOR MEASUREMENT. AND SO IF UZ ARE LIMITED IN THE SAMPLE SIZE THAT YOU CAN GET, INVEST YOUR TIME IN IDENTIFYING AND DEVELOPING HIGHLY RELIABLE MEASURES. ANOTHER THING THAT CAN HELP YOU, AGAIN, IF YOU'RE WORKING WITH LIMITED SAMPLE SIZE IS REPEATED MEASURES. SO IF YOU'RE DOING SOME KIND OF A TREATMENT STUDY, IF YOU CAN GET MULTIPLE PRE-TESTS AND MULTIPLE POST-TESTS AND LOOK TETRAJEK TRI SOMEONE K TRAJECTORY, YOU CAN GAIN A LOT OF POWER SIMPLY BY HAVING THOSE REPEATED MEASURES. SO SAMPLE SIZE, SAMPLE SIZE, SAMPLE SIZE, SAMPLE SIZE PLUS WILL ADD REPEATED LIABILITY AND MEASURES ON TOP OF THOSE. >> THIS IS ALL ABOUT SAMPLE SIZE, RIGHT? NEXT QUESTION IS DIRECT TO LAUREN. IT'S VERY INTERESTING DATA, LAUREN. DID YOU ASSESS PAIN COMORBIDITIES IN THE PATIENTS AND THEIR SPECIFIC DISEASE AND HEALTH CONTROLS THAT YOU HAD ENROLLED IN YOUR STUDIES, SINCE COPCs COULD INFLUENCE THE RESULTS? NOW THE DISEASE SPECIFIED HERE IS ME NIN -- >> THIS WAS ACTUALLY A BRAIN LESION STUDY SO WE COMPARED PATIENTS WITH LESIONS TO CONTROLS AS WELL AS SAMPLE OF PATIENTS WITH LESIONS IN OTHER BRAIN AREAS, AND THERE WERE NO DIFFERENCES IN ANY PAIN MEASURES OR ANY PSYCHOLOGICAL INDICES. SO REALLY, THE DIFFERENCES WE SAW WERE SPECIFIC TO THIS LEARNING COMPONENT. AND TO OUR SURPRISE, THERE WERE NO DIFFERENCES IN GENERAL CHRONIC PAIN QUESTIONNAIRES OR ANY KIND OF MEDICAL OR PSYCHOLOGICAL FACTORS. SO IT WAS QUITE SURPRISING TO US BUT I THINK VERY CONSISTENT WITH CURRENT VIEWS ON THE ROLE OF -- PREFRONTAL CORTEX. >> THANK YOU VERY MUCH. NEXT QUESTION IS DIRECT TO DR. BAUER. VERY INFORMATIVE TALK. LATENT CLASS ANALYSIS AND A SIMILAR APPROACH ARE BASED ON PROBABILITY. IN RESEARCH AND CLINICAL PRACTICE, WHAT DO WE DO WITH PEOPLE WHO DON'T FIT PERFECTLY WITH ONE GROUP? IN OTHER WORDS, NOT TYPICAL? >> YEAH, THAT'S A GREAT QUESTION. ONE OF THE REASONS WHY I LIKE LATENT PROFILE AND LATENT CLASS ANALYSIS IS IT CREATES A FUZZY CLUSTERING, SO IT'S NOT FORCING A PARTITION ON YOUR SAMPLE, IT'S SAYING, WELL, THIS PERSON HAS 90% CLANS OF BEING IN S CLASS AND THIS PERSON HAS 60% CHANCE OF BEING IN THIS CLASS. IF YOU HAVE INDIVIDUALS THAT DON'T CLASSIFY VERY NEATLY, THEY MIGHT HAVE KIND OF A SPLIT. YOU MIGHT NOT BE SURE. THEY MIGHT BE OVER HERE, BUT THEY ALSO MIGHT BE OVER THERE. WE CAN CALCULATE ESSENTIALLY WEIGHTED ESTIMATES OF WHAT SOMETHING LIKE TREATMENT MIGHT LOOK LIKE FOR THAT PERSON GIVEN THEY'RE 60% LIKELY TO BE IN THIS CLASS AND 40% LIKELY TO BE IN THAT ONE. SO IT'S CERTAINLY POSSIBLE TO HAVE PEOPLE WHO KIND OF LIE IN BETWEEN, AND THE WAY I LIKE TO THINK ABOUT IT IS THE PROFILES, THEY'RE SORT OF LIKE LANDMARKS IN THIS COMPLEX MULTIDIMENSIONAL SPACE OF ALL THESE VARIABLES, RIGHT? WE CAN'T THINK IN 10 CONTINUOUS DIMENSIONS AT ONCE, BUT WE CAN IDENTIFY PROFILES WITHIN THAT 10 DIMENSIONAL SPACE AND SAY OH, THIS PERSON KIND OF LOOKS LIKE THAT, OR THIS PERSON MIGHT BE IN BETWEEN THESE TWO PROFILES BUT LOOKS DIFFERENT THAN THOSE OTHER THREE. AND SO IN THAT SENSE, I THINK IT'S OKAY TO HAVE SOME PEOPLE WHO DON'T FALL NEATLY INTO ONE CATEGORY VERSUS ANOTHER. THERE ARE SOME MORE COMPLEX APPROACHES THAT KIND OF ALLOW FOR UNCLASSIFIABLE INDIVIDUALS, SO YOU KIND OF HAVE LIKE A CLASS THAT'S JUST ALMOST LIKE NOISE, IT'S LIKE THE PEOPLE WHO DON'T FIT, AND THEN THE OTHER CLASSES CAPTURE THE DENSE REGIONS WHERE YOU DO SEE PEOPLE KIND OF CLUSTERING IN THEIR CONFIGURATIONS. >> THANK YOU, THANK YOU. AND NEXT QUESTION IS DIRECT TO DR. JENSEN. THE QUESTION ACTUALLY FOLLOWS WITH CLARIFICATION THAT IT'S NOT RELATED TO COMMENTS ON NOT USING P VALUE, SO THEN WE COME TO THE QUESTION ITSELF. DR. JENSEN, WOULD YOU ADVOCATE FOR INSTEAD OF PHASING IESKTTIVENESS EFFECTIVENESS ON PATIENTS EXPECTATIONS WHAT PAIN IS MEANINGFUL TO THE PATIENTS? IF SO, CAN YOU COMMENT ON HOW YOU WOULD CONSIDER THIS IN THE CONTEXT OF VARIABLE INDIVIDUAL PATIENTS' EXPECTATIONS? SHOULD WE BE MEASURING EXPECTATIONS MORE CONSISTENTLY AND USING THAT TO GUIDE OUR TREATMENT? SO ESSENTIALLY RELATED TO PAIN AND EXPECTATION. >> SO WE DO MEASURE OUTCOME EXPECTANCIES IN EVERY ONE OF OUR CLINICAL TRIALS. I THINK IT'S IMPORTANT TO MEASURE, AND I THINK IT'S IMPORTANT TO EVALUATE WHAT IS THE ROLE OF EXPECTANCIES IN THIS PARTICULAR TREATMENT VERSUS OTHER TREATMENTS, BECAUSE THEY DO VARY FROM TREATMENT TO TREATMENT. SOME TREATMENTS ARE MORE RESPONSIVE TO ECT PECK EXPN OTHERS. SO I DO THINK IT'S IMPORTANT TO ASSESS IT IN EVERY TRIAL, EXAMINE THAT, AGAIN, OFTEN IN SECONDARY ANALYSES. I WASN'T -- IF I UNDERSTOOD THE FIRST PART OF THE QUESTION CORRECTLY ABOUT LOOKING AT MEANINGFUL CHANGE IN PAIN, IN OUR STUDIES, WE OFTEN MEASURE NOT JUST IS THERE A STATISTICALLY SIGNIFICANT DIFFERENCE BETWEEN THE CONDITIONS, WHICH IS OFTEN OUR PRIMARY ANALYSIS, BUT AGAIN, ANOTHER SECONDARY ANALYSIS IS A RESPONDER ANALYSIS. HOW MANY PEOPLE IN EACH GROUP OBTAINED A MEANINGFUL CHANGE IN PAIN. AND THE STANDARD IN THE FIELD IS USUALLY ABOUT TWO POINTS ON A ZERO TO 10 SCALE FOR SOMEBODY TO REPORT THAT MUCH CHANGE, PEOPLE ON AVERAGE SAY THAT WAS MEANINGFUL TO ME. IT WASN'T AN ELIMINATION, IT WASN'T A COMPLETE REDUCTION, BUT MEANINGFUL. LESS THAN 2 OUT OF 10, PEOPLE CAN NOTICE, BUT THEY SAY OFTEN IT WASN'T THAT MEANINGFUL. SO I THINK IT'S VERY USEFUL TO INCLUDE RESPONDER ANALYSES IN YOUR ANALYSES AND THEN LOOK AT PREDICTS WHO RESPONDS TO THIS TREATMENT, WHO IS A RESPONDER VERSUS A NON-RESPONDER. AGAIN, THESE ARE SECOND DI SECOY ANALYSES, OF WHICH THERE ARE TENS AND MAYBE EVEN A HUNDRED WHEN THEY'RE REPORTED, SO IT'S IMPORTANT TO SAY, TO MAKE IT CLEAR, THESE ARE SECONDARY EXPLORATORY ANALYSES THAT THEN NEED TO BE REPLICATED. BUT GET THEM IN THE FIELD, I WOULD SAY SUBMIT THOSE TO THE JOURNAL OF PAIN. THANK YOU FOR THE CITATIONS FOR THOSE OF YOU SPEAKERS WHO REPORTED YOUR RESULTS FROM THE JOURNAL PAIN, BUT I'M LEAVING AS EDITOR THIS MONTH SO I WON'T BE NECESSARILY ADVOCATING STRONGLY FOR THE JOURNAL PAIN OTHER THAN IT'S A GREAT JOURNAL. BUT ANYWAY, AS AN EDITOR, I LOVE TO SEE SECONDARY ANALYSES ABOUT THESE CRITICAL ISSUES. >> WONDERFUL, WONDERFUL. NOW, THE CORE QUESTION FOR THIS PANEL REALLY IS ABOUT THE TWO WORLDS AND APPROACHES THAT CAN BE USED TO ADDRESS THE BIG QUESTION THAT RAISED IN THIS YEAR'S SYMPOSIUM, THAT IS, WHOLE BODY, WHOLE PERSON APPROACH. NOW WE DEFINITELY TALK A LOT ABOUT DIFFERENT APPROACHES, DIFFERENT TOOLS, AND THERE'S EVEN MORE, WE DO NOT HAVE ENOUGH TIME TO COVER, AND ALSO THE DIRECTIONS PRESENT IN YOUR OVERVIEW -- NOW ONE OF THE THINGS THAT YOU ALSO MENTIONED THIS PROBLEMATIC APPROACH, THAT IN FACT WE TALK VERY LITTLE -- I MEAN, THE QUESTION RAISED VERY LITTLE ADDRESS TO THAT. MOST QUESTIONS STILL ADDRESS TO HOW TO DESIGN THE STUDY. HOWEVER, THE PRAGMATIC APPROACH REALLY IS TALKING ABOUT WHAT HAPPENED REAL WORLD FOR THE PURPOSE OF TREATMENT. SO I JUST WONDER, ANOTHER APPROACH WE NEVER MENTIONED HERE COULD BE USEFUL, I INVITE COMMENTS FROM MY PANEL MEMBERS, THAT IS DATA SCIENCE. IF WE COMBINE THE PRAGMATIC APPROACH, NOT NECESSARILY PRAGMATIC TRIAL BECAUSE THIS MAY HAVE DIFFERENT DEFINITIONS IN DIFFERENT PEOPLE'S MIND, BUT I'M TALKING ABOUT THE REAL WORLD APPROACH, COMBINED WITH BIG DATA SCIENCE, COMPUTATIONAL SCIENCE AND COMBINE THOSE DIFFERENT APPROACHES TO ADDRESS REAL WORLD QUESTIONS. MIGHT THAT BE A WAY TO RESOLVE SOME ISSUES LIKE POWER ANALYSIS? WE MENTIONED WE TALK A LOT, THERE'S OTHER QUESTIONS RELATED TO THAT, SO I WILL STOP HERE AND JUST INVITE YOUR COMMENTS, MY PANEL MEMBERS. >> SO THE QUESTION IS, BASICALLY, IF WE MOVE TOWARD BIG DATA AND NATURALISTIC DATA, WILL IT HELP ADDRESS SOME OF THESE QUESTIONS? >> LET ME ELABORATE FROM A DIFFERENT APPROACH. NOW, GOOGLE. GOOGLE MAKES A BIG SPLASH A FEW YEARS AGO ANNOUNCING THAT THEY ARE ABLE TO PREDICT THE INFLUENZA, THE FLU SEASON. WITHOUT ANY BIOLOGICAL DATA. WHAT THEY ARE BASED ON IS HOW MUCH THE FACE MASK HAVE BEEN SOLD IN ONE AREA. IN COMPARISON TO OTHER. AND THAT GIVES THEM A HINT. AND THAT'S BASED UPON SALES AND THERE'S BIG DATA COLLECT ALL TOGETHER, GIVE THEM THE POWER TO PREDICT THAT. AND THAT TURNED OUT TO BE VERY ACCURATE. SO I'M THINKING IN THE CLINICAL PRACTICE THAT EVERY -- IF WE HAVE THE SYSTEM. I'M ASKING THIS WITHOUT THINKING HOW MUCH COST THERE WOULD BE AND IT MIGHT NOT BE -- IT MIGHT BE A LOT, JUST TALKING ABOUT APPROACH SAYING ALL CLINICS, WE COLLECT SYMPTOMS, AND WE -- SYMPTOMS RELATED TO PAIN WITH DIFFERENT TREATMENTS, AND ACCUMULATE ALL THE PIECES OF INFORMATIONS AND OF COURSE GRADUALLY AFTER A WHILE, WE CAN IDENTIFY WHAT ARE MEANINGFUL DATA ELEMENTS THAT CAN BE USED FOR BIG DATA APPROACHES THAT MAY GIVE US A DIFFERENT ANGLE TO ADDRESS THE ISSUES OF THEIR WHOLE PERSON OR WHOLE BODY APPROACH. YES. >> 2-MINUTE WARNING. >> I'LL MAKE A QUICK COMMENT. I THINK IT DEPENDS ON HOW GOOD OUR DATA ARE. IF ALL OF OUR DATA ARE MEASURED ON WHITE MALES, THEN I THINK THAT THE MACHINE LEARNING APPROACHES AND ALL THAT ARE GOING TO BE BIASED JUST LIKE OUR TREATMENTS CURRENTLY ARE, SO WE KNOW THAT WOMEN AND NON-WHITE INDIVIDUALS ARE LESS LIKELY TO BE TREATED FOR PAIN, AND THE STIMULUS SETS THAT WE HAVE OF PATIENTS AND PAIN THAT ARE USED FOR TREATMENT ARE GENERALLY ALL WHITE INDIVIDUALS. SO I THINK THAT ANY OF THESE KINDS OF BIG DATA APPROACHES ARE SENSITIVE TO WHAT DATA ARE PUT INTO THE MODELS, AND SO I THINK WE AS RESEARCHERS AND CLINICIANS HAVE A RESPONSIBILITY TO MAKE SURE THAT THE DATA THAT ARE USED FOR THESE KINDS OF APPROACHES ARE REPRESENTATIVE OF THE POPULATION THAT WE KNOW THE LIMITATIONS IN THESE APPROACHES. SO I THINK LIKE A.I. IS GREAT, BUT IT DEPENDS ON HOW GOOD THE DATA ARE. WE KNOW THERE'S A LOT OF BIASES THERE. SO THAT'S MY 2 CENTS. >> WE HAVE ABOUT 30 SECONDS. ANY LAST COMMENTS? IF NOT, I WOULD LIKE TO TAKE THIS OPPORTUNITY TO THANK YOU VERY MUCH, ALL OF MY SPEAKERS, AND VERY ENJOYABLE TO WORK TOGETHER ON THIS PANEL. THANK YOU VERY MUCH. >> THANK YOU. >> THANK YOU, EVERYONE, FOR THAT WONDERFUL TALK. I'M MO NOW GOING TO INTRODUCE MY COLLEAGUE, DR. SARAH WOLLER. SHE IS THE SCIENTIFIC PROJECT MANAGER WITHIN THE NATIONAL INSTITUTE OF NEUROLOGICAL DISORDER AND STROKE DIVISION AND SHE'S GOING TO TAKE US THROUGH OUR SECOND JUNIOR POSTER SESSION. THANKS. >> THANKS FOR THAT INTRODUCTION. SO AS THE FIRST SESSION, WE'LL HAVE FIVE PRERECORDED TALKS AND WE WILL HAVE TIME FOR QUESTIONS FOLLOWING THE TALK VIDEOS. SO IF YOU HAVE QUESTIONS, PLEASE PUT THEM IN THE Q & A BOX. TODAY OUR SPEAKERS INCLUDE MOLLY JARMAN, ASSISTANT PROFESSOR OF SURGERY AT BRIGHAM AND WOMEN'S HOSPITAL IN HARVARD MEDICAL SCHOOL, AND SHE'LL BE PRESENTING A PRE-HOSPITAL OPIOIDS AND SHORT TERM OUTCOMES FOR OLDER ADULTS WITH FALL-RELATED INJURY. NEXT WILL BE MAICHOU LOR, ASSISTANT PROFESSOR AT THE UNIVERSITY OF WISCONSIN-MADISON SCHOOL OF NURSING PRESENTING "ENGAGING A LIMITED ENGLISH PROFICIENT POPULATION IN DESIGNING AND EVALUATING A PAIN QUALITY ASSESSMENT INFORMATION VISUALIZATION TOOL TO IMPROVE PATIENT-INTERPRETER-PROVIDER COMMUNICATION." NEXT WILL BE LIZ LOSIN, ASSISTANT PROFESSOR IN THE DEPARTMENT OF PSYCHOLOGY AT UNIVERSITY OF MIAMI, AND SHE'LL BE PRESENTING "SOCIOCULTURAL MECHANISMS UNDERLYING DISPARITIES PAIN ASSESSMENT AND TREATMENT DURING TELEMEDICINE." NEXT WILL BE SARAH NELSON, ASSISTANT PROFESSOR IN THE DEPARTMENT OF PSYCHIATRY AT HARVARD MEDICAL SCHOOL AND DEPARTMENT OF ANESTHESIOLOGY CRITICAL CARE AND PAIN MEDICINE AT BOSTON CHILDREN'S HOSPITAL, AND SHE'LL BE PRESENTING THE ROLE OF NEUROBIOLOGICAL MECHANISMS OF STRESS IN PAIN MAINTENANCE AND MIND-BODY INTERVENTION RESPONSE IN YOUTH WITH CHRONIC PAIN. AND FINALLY, ELLEN STAEDTLER, VISITING FELLOW IN THE DEPARTMENT OF PERIOPERATIVE MEDICINE AT THE NIH CLINICAL CENTER WILL BE PRESENTING "STEP BY STEP TOWARDS IMPROVED HEALTH SENSORY PHENOTYPING OF FEET AFFECTED BY MORTON'S NEUROMA AND REDUCING REFRACTORY PAIN WITH AN INJECTION OF RESINIFERATOXIN." SO AT THIS TIME WE'LL PLAY THE VIDEOS. >> HELLO. I'M MOLLY JARMON. THE WORK I'M PRESENTING TODAY WAS SUPPORTED BY A K01 AWARD FROM THE NATIONAL INSTITUTE ON AGING. 3 MILLION OLDER ADULTS EXPERIENCE A FALL-RELATED INJURY EACH YEAR IN THE UNITED STATES. ACCOUNTING FOR 17% OF ALL 911 CALLS FOR EMERGENCY MEDICAL ASSISTANCE. NATIONAL GUIDELINES FOR EMS CARE RECOMMEND OPIOID ANALGESIA FOR THE TREAT M OF TREATMENT E INJURED PATIENTS REACH THE HOSPITAL. PAIN MANAGEMENT IN OLDER ADULTS REQUIRE SPECIAL CONSIDERATION DUE TO THE RISK OF DELIRIUM, WHICH IS INCREASED BOTH BY PSYCHOACTIVE MEDICATIONS LIKE OPIOIDS AND BY SEVERE ACUTE PAIN. CURRENTLY, THERE ARE NO SPECIFIC GUIDELINES FOR PRE-HOSPITAL PAIN MANAGEMENT IN OLDER ADULTS. OUR EARLY WORK IN THIS DOMAIN SHOWS THAT 7% OF INJURED OLDER ADULTS RECEIVE OPIOIDS IN THE PRE-HOSPITAL SETTING. AND TREATMENT OF PAIN WAS CORRELATED WITH HIGHER PAIN SCORES AND MORE SEVERE INJURIES. AND WAS NOT ASSOCIATED WITH INCREASED RISK OF COMPLICATIONS SUCH AS ALTERED MENTAL STATUS OR RESPIRATORY DISTRESS REPORTED BY EMS. TO DETERMINE IF PRE-HOSPITAL OPIOID PAIN MANAGEMENT WAS ASSOCIATED WITH SHORT TERM CLINICAL OUTCOMES FOLLOWING FALL-RELATED INJURY, WE LINKED EMS PATIENT CARE REPORTS FROM THE ILLINOIS DEPARTMENT OF PUBLIC HEALTH WITH MEDICARE CLAIMS DATA FOR OLDER ADULTS DIAGNOSED WITH A FALL IN 2014 AND 2015. WE USED INVERSE PROBABILITY OF TREATMENT WAITING TO ADJUST FOR COMPOUNDING BY AGE, SEX, RACE, FRAILTY, COMORBIDITIES, INJURY SEVERITY, PRESENCE OF A TRAUMATIC BRAIN INJURY, TOTAL PRE-HOSPITAL TIME, PRE-HOSPITAL VITAL SIGNS AND TRAUMA CENTER DESIGNATION. WE USED REGRESSION TO COMPARE TOTAL PATIENT DAYS AND INTENSIVE CARE DAYS -- FOR PATIENTS WITH AND WITHOUT PRE-HOSPITAL OPIOID PAIN MANAGEMENT. IN OUR SAMPLE OF 28,000 OLDER ADULTS, 70% WERE FEMALE, 94% WERE WHITE AND THE MEAN AGE WAS 82. 3% RECEIVED A A PRE-HOSPITAL OPIOID PAIN MANAGEMENT, THE MEAN LENGTH OF STAY WAS 4 DAYS, 2% WERE DIAGNOSED WITH DELIRIUM DURING THEIR HOSPITAL STAY. PRE-HOSPITAL OPIOID PAIN MANAGEMENT WAS ASSOCIATED WITH A 9% DECREASE IN TOTAL LENGTH OF STAY AND A 20% DECREASE IN ICU LENGTH OF STAY, WHILE ODDS OF DELIRIUM DIAGNOSIS WERE NOT SIGNIFICANTLY DIFFERENT FOR PATIENTS WITH AND WITHOUT PRE-HOSPITAL OPIOID PAIN MANAGEMENT. OUR FINDINGS SHOW PRE-HOSPITAL OPIOID MANAGEMENT DOES NOT DECREASE FOR ADULTS WITH A FALL RELATED INJURY AND MAY REDUCE TIME SPENT IN THE HOSPITAL. OUR NEXT STEPS INCLUDE ASSESSMENT OF LONG TERM OUTCOMES INCLUDING DEMENTIA AND CHRONIC PAIN -- >> HI, I'M AN ASSISTANT PROFESSOR FROM THE UNIVERSITY OF WISCONSIN-MADISON. CURRENTLY THERE ARE NO CULTURALLY APPROPRIATE INFORMATION VISUALIZATION INFO VIZ TOOLS FOR LEP PATIENTS AND INTERPRETERS TO COMMUNICATE WITH HEALTHCARE PROVIDERS DURING PAIN ASSESSMENT AND MANAGEMENT. THE PURPOSE OF THIS STUDY WAS TO DEVELOP A CULTURALLY APPROPRIATE INFO VIZ PAIN QUALITY ASSESSMENT TOOL USING A MULTISTEP USER CENTERED APPROACH. WE CONDUCTED THIS STUDY IN THREE PHASES ADDRESSING THREE AIMS. PHASE ONE ADDRESSES A1 WHERE LEP AND BILINGUAL HMONG PARTICIPANTS AND INTERPRETERS EVALUATED AND PROVIDED SUGGESTIONS DOCTOR FOR INITIAL SET OF PAIN QUALITY INFOGRAPHICS CREATED IN A PREVIOUS STUDY. PHASE TWO ADDRESSES WHERE WE NARROW THE NUMBER OF PAIN INFO GRAPHICS TO 15 AND CONDUCTED CARD SORTING SESSIONS TO GATHER DATA ON ORGANIZING THE 15 PAIN QUALITY INFOGRAPHICS ON INVO VIZ TOOL ACCORDING TO THE MENTAL MODELS OF THE YOUNG ADULTS. PHASE 3 ADDRESSES AIM 3 WHICH IS TO IDENTIFY A TOOL THAT ACCURATELY REPRESENT MENTAL MODEL AND IS PREFERRED TO BE USED IN THE CLINICAL SETTING. OVERALL, THE MAJORITY OF PARTICIPANTS WERE FEMALE WITH THE MEAN AGE OF 62 FOR LEP HMONG, 39.5 FOR BILINGUAL HMONG, AND 39 FOR HMONG INTERPRETERS. FOR AIM ONE, THERE WERE THREE COMMON THEMES THAT AROSE FROM PARTICIPANTS' SUGGESTIONS DURING THE PARTICIPATORY DESIGN SESSIONS. THE FIRST WAS THE USE OF CULTURALLY RELEVANT COLORS. PARTICIPANTS CONSISTENTLY EMPHASIZED TWO COLORS THAT HAVE CULTURE MEANINGS AS VISUAL SYMBOLS, RED AND WHITE. RED CULTURALLY INDICATE PAIN OR HURTING AND DIFFERENT SHADES OF RED INDICATE PAIN SEVERITY. FOR EXAMPLE, LIGHT RED IS LESS INTENSE PAIN WHILE DARK RED IS MORE OR SEVERE PAIN. HENCE PARTICIPANTS ADJUSTED ADDING RED TO PAIN QUALITY THAT THEY PERCEIVE AS PAINFUL, AND THIS IS ALSO ILLUSTRATED IN THE SAMPLE QUOTE HERE. SEVERAL PARTICIPANTS SUGGESTED THAT CREAMY WHITE SHOULD REPRESENT NUMBNESS TO DISTINGUISH IT FROM PAIN SINCE IT DID NOT ASSOCIATE NUMBERS WITH PAIN. THE SECOND THING WAS USE OF INFO GRAPHICS TO RESEMBLE HUMAN ANATOMY. MANY EXPRESS THAT WITHOUT HUMAN FIGURE IT WAS UNCLEAR WHETHER THE PAIN WAS REAL AND THEY COULD NOT UNDERSTAND WHAT THE PAIN WAS. THE THIRD THING WAS THE USE OF ACTION-SPECIFIC QUIGLEY LINES. PARTICIPANTS CONSISTENTLY REQUESTED SQUIGGLY BEING BE ADDED FOR CRAMPS, NUMBNESS, SORENESS, PRESSURE AND ACHINESS AS ILLUSTRATED IN THIS QUOTE. FOR AIM TWO, WE IDENTIFIED THREE MAIN THEMES FROM THE CODE SORTING SESSION AMONG PARTICIPANT CREATED CATEGORIES. THESE INCLUDED SENSATION, LOCALIZATION, AND SEVERITY. FOR AIM THREE, 13 OF THE 21 PARTICIPANTS SELECTED THE LOCALIZATION OF PAIN QUALITY AS THE MOST APPROPRIATE TOOL REPRESENTING THEIR MENTAL MODEL AS PREFER TO USE IT IN THE CLINICAL SETTINGS. IN CONCLUSION, WE USE A MULTISTEP USER CENTERED APPROACH TO -- ASSESSMENT TOOL FOR QUALITY OF PAIN IN LEP HMONG PATIENTS. WE ARE CURRENTLY TESTING THIS TOOL IN THE PRIMARY CARE SETTING AND HOPE THAT IT WILL INCREASE THE CHANCES OF SUCCESSFUL IMPLEMENTATION. THANK YOU. >> HI. I'M DR. ELIZABETH LOSIN, CURRENTLY ASSISTANT PROFESSOR IN THE DEPARTMENT OF PSYCHOLOGY AT THE UNIVERSITY OF MIAMI. IN MARCH 2023, I'LL BE STARTING A POSITION AS THE BENNETT PIERCE ASSOCIATE PROFESSOR OF CARING AND COMPASSION IN ADULTHOOD IN THE DEPARTMENT OF BIOBEHAVIORAL HEALTH AT PENN STATE UNIVERSITY. TODAY I'M GOING TO BE PRESENTING PRELIMINARY RESULTS FROM A STUDY ON SOCIOCULTURAL MECHANISMS UNDERLYING DISPARITIES IN PAIN ASSESSMENT AND TREATMENT DURING TELEMEDICINE. SUPPORTED BY MY K01 AWART FROM THE NATIONAL INSTITUTE ON DRUG ABUSE. OUR MAIN RESEARCH QUESTION WAS HOW DO CLINICIANS CONTRIBUTE TO PAIN TREATMENT DISPARITIES, NAMELY, WOMEN AND MINORITIZED INDIVIDUALS TEND TO BE PRESCRIBED LESS PAIN TERRITORIMENT THAN IS CLINICALLY INDICATED LEADING TO POOR PAIN MANAGEMENT IN THESE GROUPS, WHILE MEN AND NON-HISPANIC WHITE INDIVIDUALS ARE OFTEN PRESCRIBED MORE PAIN TREATMENT THAN IS CLINICALLY INDICATED CONTRIBUTING TO THE OPIOID EPIDEMIC. WE HAD MEDICAL STUDENTS AND RESIDENTS PLAY THE ROLE OF CLINICIANS IN SIX TELEMEDICINE APPOINTMENTS EACH. PATIENTS WERE TRAINED COMMUNITY MEMBERS WITH FICTITIOUS SHOULDER INJURIES, ALL MET CLINICAL CRITERIA FOR THE USE OF OPIOID ANALGESICS. EACH CLINICIAN WOULD TAKE A MEDICAL HISTORY, PERFORM THE MAYO CLINIC REMOTE MUSCULOSKELETAL SHOULDER EXAM. YOU CAN SEE A SCREEN SHOT HERE. THEY'RE NOT JUST DOING A DAB. AND FINALLY, THE CLINICIAN WOULD MAKE AN ASSESSMENT OF THE PATIENT'S PAIN AND PHARMACOLOGICAL AND NON-PHARMACOLOGICAL TREATMENT DECISIONS. MY GRADUATE STUDENT AND I USED STRUCTURAL EQUATION MODELING TO TEST WHETHER PATIENT DEMOGRAPHICS INFLUENCE PAIN ASSESSMENT AND TREATMENT DECISIONS, AND IF SO, WHETHER DEMOGRAPHIC STEREOTYPES AND OPIOID ABUSE STEREOTYPES MEDIATED THIS RELATIONSHIP. WE ALSO CONTROLLED FOR SEVERAL VARIABLES INCLUDING THE CLINICIAN'S MEDICAL EXPERIENCE. INTERESTINGLY, IN THE 119 INTERACTIONS ANALYZED HERE, ABOUT 30% OF OUR FINAL SAMPLE, PATIENT RACE AND ETHNICITY DID NOT INFLUENCE PAIN ASSESSMENT AND TREATMENT HOWEVER, IN THE RED PACK, YOU CAN SEE THAT THE MORE SENSITIVE THE CLINICIAN PERCEIVED THE TYPICAL PERSON FROM THAT PERSON'S RACIAL GROUP, THE MORE INTENSE THEY PERCEIVED THAT PATIENT'S PAIN. AND THE MORE LIKELY THEY REPORTED THEY WOULD BE TO PRESCRIBE THEM OPIOIDS. STRIKINGLY, THE RATINGS THE PATIENTS PROVIDED OF THEIR OWN PAIN IN BLUE DURING THE CLINICAL EXAM DID NOT INFLUENCE THE CLINICIAN'S PERCEPTIONS OF THEIR PAIN INTENSITY OR LIKELIHOOD OF PRESCRIBING ANALGESICS. TOGETHER THESE PRELIMINARY DATA SUGGEST THAT UNDER SOME CIRCUMSTANCES, CLINICIANS MAY RELY MORE HEAVILY ON THEIR STEREOTYPES ABOUT THE TYPICAL PAIN SENSITIVITY OF PEOPLE FROM A PATIENT'S ETHNIC OR RACIAL GROUP THAN THE PATIENT'S OWN PAIN REPORT. PROVIDING A POTENTIAL TARGET FOR INTERVENTION. THANKS. >> HELLO, DR. SARAH NELSON, PRESENTING ON MY RESEARCH LOOKING AT THE NEUROBIOLOGICAL MECHANISMS OF STRESS IN PEDIATRIC CHRONIC PAIN. WE KNOW PEDIATRIC CHRONIC PAIN IS A SERIOUS PUBLIC HEALTH ISSUE AND IS OFTEN ASSOCIATED WITH HIGH LEVELS OF PSYCHOLOGICAL STRESS AND EXPOSURE TO ADVERSE CHILD HOOD EXPERIENCES. PRELIMINARY MECHANISTIC WORK HAS ALSO IDENTIFIED ALLOSTATIC LOAD AND BRAIN DEVELOPMENT INCLUDING THE HIPPOCAMPUS AS POTENTIALLY IMPLICATED IN PARALLELS BETWEEN STRESS AND PAIN PERCEPTION AND PAIN RESPONSE, HOWEVER, THESE REMAIN POORLY UNDERSTOOD. IN ADDITION TO THIS, INTERVENTIONS THAT ADDRESS THE MALADAPTIVE STRESS RESPONSE LIKE MINDFULNESS BASED THERON HAVE BEEN PROPOSED TO BE PARTICULARLY RELEVANT TO PEDIATRIC CHRONIC PAIN DUE TO THEIR PREVIOUS EVIDENCE IN MODULATING STRESS AND ALTERATIONS IN THESE AREAS HOWEVER THESE INTERVENTIONS IN PEDIATRIC CHRONIC PAIN POPULATIONS PARTICULARLY FROM A MECHANISTIC STANDPOINT HAVEN'T BEEN SIGNIFICANTLY STUDIED. THEREFORE, OBJECTIVES OF MY CURRENT INVESTIGATION INCLUDE SUMMARIZING MY RESEARCH TO DATE AND NUMBER TWO, HIGHLIGHTING AN ONGOING RESEARCH FUNDED BY NCCIH THAT LOOKS AT THESE MECHANISMS IN RELATION TO MIND-BODY INTERVENTION RESPONSE IN PEDIATRIC CHRONIC PAIN. PRIMARY RESULTS OF MY STUDIES LOOK AT ALLOSTATIC LOAD AND HAVE FOUND THAT OVER 50% OF YOUTH WITH CHRONIC PAIN ARE AT HIGH RISK FOR ALLOSTATIC LOAD MEANING GREATER THAN TWO RISK FACTORS. WE'VE ALSO FOUND ALLOSTATIC LOAD MODERATE THE -- WHICH HIGHLIGHT THE POTENTIAL ROLE OF STRESS, WEAR AND TEAR AND MODULATED PAIN RELATED FUNCTIONING. IN THE CONTEXT OF MY K23, THE AIMS ARE TO FURTHER ELUCIDATE THE ROLE OF ALLOSTATIC LOAD AND BRAIN BASED MALL ADAPTATION TO STRESS IN MIND-BODY INTERVENTION RESPONSE TO GET A BETTER UNDERSTANDING OF THE MECHANISMS OF THESE INTERACTIONS AND INTERVENTIONS, I'M RECRUITING YOUTH WITH CHRONIC WIDESPREAD PAIN, A BASELINE VISIT INVOLVES AN FMRI AND QUANTITATIVE SENSORY TESTING IN ADDITION TO A MULTIFACTORIAL ALLOSTATIC LOAD COMPOSITE INCLUDING GLUCOCORTICOIDS, WAIST-HIP RATIO AND BMI AND THEN WE'RE GOING TO BRING THEM BACK FOR FOLLOW-UP FOR REPEAT COLLECTION OF ALLOSTATIC LOAD. PRELIMINARY RESULTS IN MY RECRUITED PATIENTS TO DATE FOR PAIN AND FOR HEALTHY CONTROLS OBVIOUSLY INTERPRETED WITH CAUTION BUT SHOW THAT YOUTH WITH CHRONIC PAIN ON AVERAGE ENDORSE OVERWHELMINGLY MUCH HIGHER RATE OF TRAUMATIC EVENT EXPOSURE THAN HEALTHY CONTROLS. PRELIMINARY IMAGING ANALYSES IN RESTING STATE ALSO FOUND SIGNIFICANT DIFFERENCES IN THE PERIHIPPOCAMPAL GYRATION AND LEFT HIPPOCAMPUS, SO INTERESTING PRELIMINARY RESULTS. SIGNIFICANCE OF THESE FINDINGS SHOW THAT EVIDENCE OF ALLOSTATIC LOAD RISK FACTORS AND FUNCTIONAL CONNECTIVITY MAY BE IMPORTANT TO LOOK AT AND WOULD OFFER STRONG SUPPORT FOR TARGETING THE PHYSIOLOGICAL RESPONSE FOR USING A MIND-BODY APPROACH. THANK YOU. >> MY A VISITING FELLOW IN THE DEPARTMENT OF PERIOPERATIVE MEDICINE. ON THE BASIC SIDE OUR LAB IS INTERESTED IN THE MOLECULAR MECHANISMS UNDERLYING ACUTE AND CHRONIC PAIN. ON THE CLINICAL SIDE, WE FOCUS ON OTHER TREATMENTS FOR RELIEF OF REFRACTORY PAIN. INJURY INDUCED NEUROPA TICK NEWN PROBLEMS FALL INTO THIS CLASS. MORTON'S NEUROMA IS A HIGHLY LOCALIZED LESION IN THE BOTTOM OF THE FOOTWEAR THE NERVE IS NATURALLY EXPOSED TO REPEATED MECHANICAL STRESS. WHICH CAN BE AGGRAVATED BY ENGAGING HIGH IMPACT SPORTS, POOR FOOTWEAR CHOICES. IN SOME INDIVIDUALS, THIS LEADS TO AXONAL DAMAGE, ENLARGEMENT TO FORM A NEUROMA. WE DESIGNED A CLINICAL TRIAL TO TREAT MORTON'S NEUROMA PATIENTS WITH REFRACTORY PAIN AFTER NON-SURGICAL PROCEDURES. THE POTENTIAL KEY SET OF NOCICEPTIVE -- TRIP V1. WE KNOW FROM ANIMAL STUDIES AND OTHER CLINICAL TRIALS THAT A ONE-TIME INJECTION OF RTX LEADS TO A LONG LASTING PAIN REDUCTION. RTX IS A VERY OLD REMEDY DIRECT FROM THE PLANT -- RTX EXPOSURE LEADS TO OVERFLOW INTO FIBERS AND CONDUCTION BLOCK THAT LASTS AT LEAST SEVERAL MONTHS. THIS IS SELECTIVE AND DOES NOT AFFECT MECHANICAL SENSATIONS OR MOTOR FUNCTION. WE ALSO AIM TO UNDERSTAND THE UNDERLYING PATHOPHYSIOLOGY TO ESTABLISH COLLABORATION WITH LOCAL PODIATRISTS THAT PROVIDE US WITH SURGICAL SPECIMENS OF THE NEUROMA. THIS ALLOWS US TO STUDY IN COMPARISON TO HEALTHY NERVE FIBERS AND POTENTIALLY IDENTIFY ADDITIONAL PHARMACOLOGICAL TARGETS FOR PAIN TREATMENT. IN COLLABORATION WITH THE PAIN RESEARCH CENTER, WE CHARACTERIZE THE SENSORY PROFILES OF PATIENTS WITH MORTON'S NEUROMA BY APPLYING A COMPREHENSIVE SET OF MECHANICAL AND THERMAL SOMATOSENSORY TESTS. THESE TESTS WILL NOT ONLY REVEAL HOW PATIENTS WITH MORTON'S NEUROMA PERCEIVE DIFFERENT SENSORY STIMULI BUT ALSO PROVIDE SAFETY AND EFFICACY OUT COME MEASURES OF CLINICAL TRIAL. WE THINK THAT THE KNOWLEDGE WE GATHER FROM THIS PROJECT WILL BE APPLICABLE -- POTENTIALLY RELIEVE THESE PATIENTS' PAIN. THANK YOU. THANKS TO ALL THE PEOPLE INVOLVED IN THIS PROJECT. >> ALL RIGHT, THANK YOU, EVERYONE, FOR THOSE PRESENTATIONS. IF YOU WOULD ALL TURN ON YOUR CAMERAS NOW, WE CAN GO TO A FEW QUESTIONS. THE FIRST QUESTION I HAVE IS FOR DR. JAR MAN, ONLY ASSOCIATED WITH OPIOIDS OR WITH OTHER ANALGESICS POTENTIALLY HAVE A SIMILAR EFFECT? >> SO I WOULD SAY THE SHORT ANSWER IS WE DON'T KNOW. LIKELY WE WOULD SEE A SIMILAR BENEFICIAL EFFECT, THE BENEFIT IS FROM MANAGING THE PAIN. CURRENTLY THERE ARE NO ALTERNATIVES AVAILABLE FOR MANAGEMENT OF THAT TYPE OF SEVERE ACUTE PAIN FROM SOMETHING LIKE A HIP FRACTURE: THE OPTIONS ARE IBUPROFEN AND USUALLY FENTANYL. >> GREAT. THANK YOU. IN A FOLLOW-UP QUESTION, THE MAJORITY OF THE PEOPLE IN YOUR STUDY WERE WHITE FEMALES. CAN YOU COMMENT ABOUT WHETHER YOU EXPECT YOUR RESULTS TO GENERALIZE TO OTHER POPULATIONS? >> SO THE POPULATION, IT IS PRIMARILY WHITE FEMALES, IS ACTUALLY FAIRLY REPRESENTATIVE OF THE POPULATION EXPERIENCING THESE INJURIES AT THAT AGE RANGE. I DON'T HAVE ANY REASON TO BELIEVE THE EFFECTS WOULD BE DIFFERENT. THE ONLY MECHANISMS I CAN REALLY THINK OF WOULD BE VARIATION IN KIND OF PROFILE OF COMORBIDITIES. ONE IN PARTICULAR BEING PEOPLE WHO MIGHT BE IN THE EARLY STAGES OF COGNITIVE DECLINE AND EXPOSURE MIGHT -- DEMENTIA. AT THE SAME TIME EXPOSURE TO PAIN MAY ALSO PRECIPITATE THEIR DEMENTIA, SO IT WOULD BE GREAT TO HAVE ACCESS TO DATA WITH A RICHER DEMOGRAPHIC PROFILE. >> GREAT, THANK YOU. AND THANK YOU FOR YOUR PRESENTATION. THE NEXT QUESTION WE HAVE IS FOR DR. LOR. THERE WAS A COMMENT, THE INFO GRAPHICS ARE GREAT. AND WHEN LANGUAGE IS LESS OF A BARRIER, ARE THERE RECOMMENDATIONS FOR IMPROVING VERBAL REPORT TOOLS, ESPECIALLY IN CASES WHEN A VISUAL DOESN'T SUFFICE? >> THAT'S A REALLY AWESOME QUESTION THAT I THINK I DON'T HAVE THE ANSWER TO, BUT I CAN KIND OF DRAW ON MY CURRENT KNOWLEDGE JUST LOOKING AT THE LITERATURE. I THINK IN TERMS OF TOOLS IN GENERAL FOR PAIN ASSESSMENT, THERE'S BEEN A LOT OF WORK DONE WITH PAIN SEVERITY TOOLS, SO YOU'LL GET THE SMILEY FACES, REVISED FACE THAT COULD BE USED FOR PAIN INTENSITY, BUT I THINK ONE OF MY RECOMMENDATIONS FOR IMPROVING VERBAL REPORT TOOL IS TO DO MORE RESEARCH, BECAUSE THE EXISTING RESEARCH HAVE ALWAYS BEEN JUST TRANSLATING INTO ANOTHER LANGUAGE AND THEN AROUND TESTING IT WITH THE POPULATION BUT NOT REALLY GROUNDED FROM THE PATIENT'S PERSPECTIVE UP. SO I THINK THERE NEEDS TO BE SOME MORE RESEARCH DONE TO MAKE SURE THAT PAIN INFORMATION ARE COLLECTED ACCURATELY, PARTICULARLY FOR VERBAL. I THINK ONE OF THE RECOMMENDATIONS DRAWING FROM SOME OF THE HEALTH LITERACY -- IS TO USELESS USE LESS JARGN YOU'RE TRYING TO ASSESS PAIN AND GET THE INFORMATION FROM PATIENTS, AS WELL AS VISUAL, BECAUSE I KNOW THAT WORKS VERY WELL, BUT OF COURSE YOU'RE COMMENTING ABOUT WHEN VISUAL DOESN'T WORK. SO I RO RECOMMEND WOULD E PROVIDERS REALLY TRY NOT TO USE JARGON AND PROVIDE EXAMPLES TO TALK WITH PATIENTS IN EXCESSIVE PAIN. I HOPE THAT ANSWERS YOUR QUESTION. >> HOW CAN YOUR VISH VAITION YON TOOL BE WIDELY IMPLEMENTED ACROSS SITES AND DOES IT REQUIRE TRAINING? >> YES, THAT'S A GREAT QUESTION AS WELL. WHAT WE HAVE -- ONE UNIQUE THING ABOUT THIS TOOL THAT WE REALLY TRIED TO DO IS CREATE A METHODOLOGY THAT WE CAN POTENTIALLY REPEAT TO CREATE THE VISUALS THAT WOULD WORK FOR THEM. WE HAVE ALSO INVOLVED PROVIDERS IN THE PROCESS WHICH I DIDN'T REPORT ON BUT TO GIVE US FEEDBACK ON WHAT ARE THE MOST IMPORTANT PAIN QUALITIES THAT THEY PRIORITIZE IN ASSESSING PAIN. SO WE DID INCLUDE THEM. >> ANOTHER QUESTION, DR. LOR, YOUR -- ON A -- WHAT THOUGHTS DO YOU HAVE ABOUT SYSTEMATICALLY -- AWARENESS AND PAIN IN DIFFERENT CULTURES AND DO YOU PLAN TO PROMOTE OR -- THESE TOOLS SO THEY CAN BE USED THROUGHOUT THE U.S. IN HOSPITALS AND CLINICS? >> YEAH, DEFINITELY. THAT'S A REALLY GOOD QUESTION. AS YOU'VE MENTIONED, YOU KNOW, PAIN IS EXPRESSED DIFFERENTLY ACROSS CULTURE, AND I'M CURRENTLY DOING A SYSTEMATIC REVIEW NOW TO LOOK AT HOW PAIN IS BEING EXPRESSED, SPECIFICALLY FOR POPULATION WITH LIMITED AGE PROFICIENCY BECAUSE I FEEL THAT THEY HAVE BEEN LEFT OUT OF THE PAIN CONVERSATION. SO FAR THERE'S NOT A LOT OF RESEARCH DONE IN THAT AND NOT A LOT OF TOOLS THAT HAVE BEEN CO-CREATED WITH THE POPULATION. I'M REALLY HOPING THE WORK WE'VE STARTED FOR THIS K CAN BE A ROAD MAP TO REALLY EXPAND TO OTHER POPULATIONS AND TO MAKE IT MORE ACCESSIBLE TO DIFFERENT PATIENT POPULATION AND CLINICIANS TO USE. WE'RE PILOT TESTING IT RIGHT NOW SO I CAN'T GIVE YOU WHAT THE EFFECTIVENESS IS BUT I'M HOPING THAT WILL BE THE ULTIMATE GOAL IN THE NEXT FIVE YEARS TO IMPLEMENT IT AND TO MAKE SURE WE CAN EXPAND TO OTHER POPULATIONS. >> THANK YOU SO MUCH, AND AGAIN, THANK YOU FOR YOUR PRESENTATION. I HAVE A QUESTION HERE FOR DR. LOSIN. AT THE END OF YOUR TALK, YOU MENTIONED A TARGET FOR INTERVENTION. CAN YOU EXPAND ON THAT? >> YEAH, SO THE IDEA WOULD BE IF -- YOU KNOW, THESE PRELIMINARY DATA SUGGEST THAT AT LEAST SOMETIMES CLINICIANS MAY BE RELYING MORE ON THEIR STEREO TIME TYPES ABOUT A PATIENT'S DEMOGRAPHICS, THE TYPICAL PERSON FROM THAT PATIENT'S DEMOGRAPHIC GROUP, VERSUS THE INFORMATION THE PATIENT IS PROVIDING ABOUT THEIR OWN PAIN. SO WE ARE ULTIMATELY HOPING TO INFORM AND INTERVENTION AND ACTUALLY TEST IT BASED ON THESE DATA. BUT THE IDEA WOULD BE SOMETHING THAT HELPS CLINICIANS TO SHIFT THEIR FOCUS TO THE INFORMATION THAT THE PATIENTS ARE PROVIDING THEM TO VALUE THAT MORE OR WEIGHT IT MORE HEAVILY IN THEIR PAIN ASSESSMENT AND TREATMENT DECISION-MAKING PROCESS. SO WHAT IS, WE HAVEN'T GOTTEN THERE YET. >> GREAT. THANK YOU. THE NEXT QUESTION IS FOR DR. NELSON AND THE QUESTION IS, DOES THE MIND-BODY APPROACH DEPEND ON THE AGE OF THE PATIENT? YOU'RE MUTED. >> SORRY ABOUT THAT. CAN YOU REPEAT THAT? >> THE QUESTION WAS, DOES THE MIND-BODY APPROACH DEPEND ON THE AGE OF THE PATIENT? SO I THINK ESPECIALLY IN A PEDIATRIC POPULATION, THERE'S JUST A BROAD RANGE IN THE OVERALL DEVELOPMENT TO THE STAGE OF THE PATIENT AND DOES THE APPROACH YOU TAKE DEPEND ON THE AGE? >> ABSOLUTELY. I MEAN, AS A PSYCHOLOGIST, WE DEFINITELY WANT TO CATER THE MIND-BODY APPROACH TO THE DEVELOPMENTAL LEVEL OF THE PATIENT, BUT A LOT OF THESE MORE BURGEONING MIND-BODY INTERVENTIONS LIKE MINDFULNESS BASED STRESS REDUCTION ACT, THINGS LIKE THAT, CAN BE CATERED TO ANY NUMBER OF DEMOGRAPHICS, ANY NUMBER OF AGE RANGES DEPENDING ON THE PRESENTING PROBLEM. >> AND THERE'S A FOLLOW-UP QUESTION THAT SAYS YOU TALKED ABOUT DIFFERENT MEASURES OF ALLOSTATIC LOADS. WHAT ARE THE PROS AND CONS FOR THOSE MEASURES, AND WHAT ARE THE CONSIDERATIONS FOR TIMING THESE MEASUREMENTS? >> I THINK ALLOSTATIC LOAD IS A STILL AN UP AND COMING MEASURE. THINK THE BASELINE IS YOU NEED TO HAVE A MULTIFACTORIAL -- LOOKING AT DIFFERENT TYPES OF PHYSIOLOGICAL FUNCTIONING TO KIND OF ACCUMULATE THAT RISK FOR ALLOSTATIC LOAD. THE PROS AND CONS ARE JUST LACKING AT DIFFERENT KINDS OF DEMOGRAPHICS, RISK STRATIFICATIONS, THERE'S BEEN SOME GOOD STUDIES COMING OUT LOOKING AT PEOPLE IN DIFFERENT NEIGHBORHOODS, DIFFERENT SOCIOECONOMIC STATUS. I THINK THERE'S A LOT OF CONFOUNDING FACTORS THAT COULD BE TAKEN INTO ACCOUNT THERE, BUT WE'RE REALLY EXCITED ABOUT WHERE THE FIELD IS GOING AND LOOKING AT THIS IN THE CONTEXT OF PAIN. >> GREAT, THANK YOU. WE HAVE A QUESTION FOR DR. STAEDTLER. FIRST IS WHAT ARE THE SIDE EFFECTS AND HOW LONG AFTER INJECTION BEFORE YOU CAN WALK? AND ALSO ARE MANY PEOPLE ALLERGIC? >> SO I'LL START WITH THE LAST QUESTION. NO, NOT MANY PEOPLE ARE ALLERGIC TO RTX, IT'S A CAP SIGH SIN ANALOG THAT HAS BEEN USED IN MANY DOZENS OF PEOPLE WITH DIFFERENT ROUTES OF ADMINISTRATION, INTRATHECALLY OR INJECTIONS EPIDURALLY, AND THERE HAS NEVER BEEN A REPORT OF AN ANAPHYLACTIC OR ALLERGIC REACTION, SO IN THEORY THAT'S POSSIBLE BUT HAS NOT BEEN OBSERVED SO FAR, SO IT DOESN'T SEEM TO BE A STRONG ALLERGEN PER SE. THE SECOND ONE, THE SIDE EFFECT IS IT ACTIVATES NOCICEPTIVE FIBERS, HEAT AND PAIN TRANSMITTING FIBERS, SO WHEN YOU INJECT IT OR YOU EXPOSE YOURSELF TO IT, YOU HAVE BURNING PAIN, BURNING PAIN SENSATION, WHICH CAN BE REDUCED BY INJENGTING A LOCAL ANESTHETIC FIRST SO YOU HAVE NO PAIN CONDUCTION, IT'S BLOCKED, THEN YOU INJECT THE RTX AND IN IDEAL CASE, YOU COULD HAVE PANT ANYMORE. PAIN ANYMORE. THAT'S WHAT REAR PLANNING TO DO AND ARE CONFIDENT IT CAN WORK. IT ONLY AFFECTS A CERTAIN SUBPOPULATION OF FIBERS, SO IT DOESN'T AFFECT MOTOR FIBERS, SO USUALLY RTX ITSELF DOES NOT PREVENT WALKING ABILITY, SO THAT IS TOTALLY PRESERVED. THE LOCAL ANESTHETIC THAT YOU WILL INJECT MIGHT LEAD TO A LITTLE BIT OF MAYBE -- BUT HONESTLY MOTOR FIBERS FOREFOOT MUSCLES IN THAT STAGE WHERE THE NEUROMA SITS HAVE ALREADY LEFT THE NERVE, SO THERE SHOULD BE NO MOTOR -- REDUCTION MOTOR FUNCTION AT ALL, NOT EVEN FOR THE TOES. BUT THE RTX PER SE DOES NOT AFFECT MOTOR FUNCTION. THAT WOULD BE ONLY A SIDE EFFECT OF LOCAL ANESTHETIC, IT WOULD BE VERY SHORT LASTING. ANOTHER EFFECT THAT IS KNOWN THAT IT ALSO REDUCES THE SENSITIVITY TO NOXIOUS HEAT, SO THIS IS A SMALL AREA THAT WILL BE NUMB FOR HEAT SENSITIVITY IF THE FOREFOOT BUT IF YOU HAVE INTRATHECAL APPLICATION, YOU HAVE TO WARN PATIENTS THAT THERY MIGHT NOT FEEL WHEN THEY STEP INTO A HOT BATH, FOR EXAMPLE. THAT'S IMPORTANT TO EDUCATE THEM ABOUT THIS. >> GREAT, THANK YOU. HOW IS THE DOSE OF RTX DETERMINED THAT YOU'RE USING FOR THE STUDY? >> HOW IT'S DETERMINED? IT WAS INFERRED FROM CLINICAL TRIALS, STUDIES WHERE WE USED, MY COLLEAGUES USED INJECTION IN A NERVE IN THE RAT'S LEG, AND THEN LOOK FOR EFFECTS ON INFLAMMATION, PAIN, AND SO WE USED THE DOSE THAT WAS EFFECTIVE IN PRE-CLINICAL TRIALS AS A STARTING DOSE AND THEN HAVE LIKE FOUR STEPS THAT THEY WILL INCREASE THE DOSES. IT'S USED IMMENSELY LOW CONCENTRATION SO WE START AT SOMETHING LIKE 250 NANOGRAMS. IT'S A REALLY LOW DOSE THAT'S EFFECTIVE. AND IF WE ARE POSITIVE THIS WILL HAVE AN ANALGESIC EFFECT AND WE'RE FAR AWAY FROM ANY DOSE THAT WOULD VERY LIKELY HAVE SOME SIDE EFFECTS ACTUALLY. >> THANK YOU SO MUCH. WE HAVE ANOTHER QUESTION FOR DR. THE COMMENT SAYS IT'S VERY INTERESTING THE ENDORSEMENT OF STEREOTYPE BUT NOT TARGET DEMOGRAPHICS PREDICTED PERCEIVED PAIN INTENSITY THAT THESE STEREOTYPES APPLY TO ALL CATEGORY, FOR EXAMPLE, FOR WHITE PATIENTS IN CONSIDERATION OF RACE, OR WERE THEY DRIVEN BY STEREOTYPES FOR CERTAIN TARGET DEMOGRAPHICS? >> THANKS FOR THAT QUESTION. SO THE WAY WE HAVE RUN THE SEM MODELS SO FAR, IT'S JUST PLUGGING IN THAT PARTICIPANT'S RATING OF STEREOTYPICAL PAIN SENSITIVITY FOR EACH ETHNIC AND RACIAL GROUP, AND THEN THAT'S PUT IN THE MODEL FOR EVERY PATIENT FROM THAT ETHNIC OR RACIAL GROUP. SO I CAN'T -- WITH THE WAY WE'VE DONE THE ANALYSIS SO FAR, I CAN'T SAY WHETHER STEREOTYPES ABOUT ONE SPECIFIC GROUP ARE DRIVING THAT RESULT MORE THAN OTHERS, BUT THAT IS DEFINITELY THE PLAN FOR THE NEXT STEPS IN THE ANALYSIS, BECAUSE CLEARLY THAT WELL MAY BE THE CASE. SO I DON'T KNOW YET, BUT WE'RE GETTING THERE. >> THANK YOU. AND AS A BROADER QUESTION FOR ALL OF THE PANELISTS, THAT IS, CAN YOU COMPARE AN INTERVENTIONAL TREATMENT LIKE WHAT DR. STAEDTLER WAS PROPOSING COMPARED TO THE OTHER TYPES OF TREATMENTS THAT WERE DISCUSSED ON PAIN? >> I MEAN, I CAN ADD SOMETHING. I THINK AS A PAIN PSYCHOLOGIST, ONE OF THE BIG MESSAGES THAT WE LIKE TO CONVEY IS THAT CHRONIC PAIN ESPECIALLY IS A MULTIPRONGED APPROACH, WHERE YOU COME AT IT WITH A VARIETY OF BOTH KIND OF MEDICAL AND PHARMICOLOGICAL, PHYSICAL AND MIND-BODY INTERVENTION, FIT TO MEET THE NEEDS OF EACH INDIVIDUAL PATIENT. >> THANK YOU FOR THAT. DOES ANYONE ELSE WANT TO COMMENT? >> I HOPE THAT WAS HELPFUL. >> SO IN OUR CASE, WE'RE STUDYING CLINICIANS AND THEIR PAIN TREATMENT DECISIONS, SO WHILE WE'RE NOT INTERVENING DIRECTLY ON THE PATIENT'S PAIN, I IMAGINE THAT TRAINING CLINICIANS DIFFERENTLY TO INCREASE THE EFFECTIVENESS OF THEIR PAIN MANAGEMENT AND DECREASE ANY BIASES THEY MAY HAVE WILL OBVIOUSLY HAVE AN EFFECT ON PATIENTS' PAIN AND HOPEFULLY PARTICULARLY IN ALLEVIATING PAIN OF GROUPS THAT HAVE HISTORICALLY BEEN RECEIVING LESS ADEQUATE TREATMENT. >> I CAN SHARE OURS TOOL. WITH OUR TOOL, THE GOAL IS TO REALLY FACILITATE THAT COMMUNICATION SO THAT PROVIDERS DON'T NEED TO LEARN THE PATIENT'S LANGUAGE OR MENTAL MODEL OF HOW PAIN IS BEING CONCEPTUALIZED, AND SO THE WAY WE HAVE MAPPED OUR TOOL IS TO HAVE THE PATIENT'S PAIN DESCRIPTOR IN THEIR OWN LANGUAGE THAT ARE METAPHORS OF HOW THEIR PAIN IS BEING EXPRESSED. THE ROLE OF THE INTERPRETER IS REALLY TO HELP FACILITATE THAT, NOT TO GIVE MORE WORK TO THE INTERPRETER, WE'VE MAPPED OUT THOSE METAPHORS TO WHAT PROVIDERS WOULD EXPECT FOR PAIN QUALITY OR PAIN SEVERITY AS WELL. I DIDN'T FOCUS ON PAIN SEVERITY BUT THAT'S ALSO PART OF THE WORK WE'RE WORKING ON AS WELL. SO HOW THAT COMPARED TO USUAL CARE, USUAL CARE, YOU KNOW, PATIENTS ARE BEING ASKED HOW TO DESCRIBE THEIR PAIN OR IF YOU'VE NEVER HAD PAIN BEFORE, YOU MIGHT EXPRESS IT DIFFERENTLY THAN WHAT YOU WOULD EXPECT IN THE WESTERN KIND OF CULTURE FROM PROVIDERS. SO THAT'S KIND OF HOW WE'RE TESTING IT, COMPARING IT WITH USUAL CARE, JUST THE USUAL -- COMPARE IT WITH WHAT PROVIDERS WOULD ASK THE PATIENT, WHAT THAT COMES OUT TO BE, AND COMPARE IT WITH OUR TOOL, HAVING THIS MAPPED OUT INFOGRAPHIC TOOL THAT WOULD HELP FACILITATE THAT COMMUNICATION BETWEEN PATIENTS, PROVIDER AND THE INTERPRETER, WHAT THAT WOULD LOOK LIKE FOR PAIN ASSESSMENT AND TREATMENT AS WELL. >> THOSE ARE ALL REALLY IMPORTANT POINTS AND IS THERE -- DO ANY OF THE OTHER PANELISTS HAVE ANYTHING TO ADD? ALL RIGHT. I THINK WE DON'T HAVE ANY MORE QUESTIONS AT THIS TIME, SO I CAN GIVE YOU ALL ONE MORE CHANCE IF YOU HAVE ANYTHING ELSE TO ADD OR ANYTHING ELSE YOU'D LIKE TO MENTION. IF NOT, I CAN TURN THIS BANK OVER FOR THE WRAP-UP. ALL RIGHT. THANK YOU ALL. INA, ARE YOU ON NOW? INNA, ARE YOU ON NOW? SORRY, LEAH, DO YOU OR ANY UNONE ELSE HAVE THE -- DO YOU WANT TO DO THE CLOSE OF THE SESSION? >> SURE, I CAN GIVE CLOSING REMARKS. >> THANKS, MELISSA. >> THEY MAY HAVE JUST STEPPED AWAY. I THANK ALL THE OTHER ORGANIZERS, THE -- THE MODERATORS, THE FACILITATORS, EVERYONE HAS REALLY PUT IN -- INTO THE CONTENT. HELLO, INNA. >> HELLO. I WAS FROZEN. BUT THANK YOU FOR STEPPING IN. >> TAKE IT AWAY. >> NO PROBLEM. THANK ALL THE JUNIOR INVESTIGATORS FOR THIS EXCELLENT SESSION, AND FOR ALL THE DATA THAT YOU WORKED ON. THIS WAS REALLY GREAT. FOR ALL THE QUESTIONS, THANK YOU FOR THE -- TO OUR DEDICATED AUDIENCE, AND I ALSO LIKE TO THANK EVERYONE WATCHING THE VIDEOCAST FOR JOINING TODAY, AND REMIND YOU ALL THAT YOU PLEASE SHOULD JOIN US AGAIN TOMORROW FOR DAY TWO, BEGINNING AT 11:00 A.M. EASTERN TIME. THE NIH VIDEOCAST. AND PLEASE USE YOUR SAME LINK TO LOG IN TOMORROW, AND WITH THIS, HAVE A GREAT EVENING. THANK YOU SO MUCH. AND SEE YOU TOMORROW.